Criminal Code

Canada,

Province of ,

(territorial division).

Be it remembered that on the day of A.D. , at in the (territorial division), E.F. of , hereinafter called the defaulter, is convicted by me for contempt in that he did not attend before (set out court or justice) to give evidence on the trial of a charge that (state fully offence with which accused was charged), although (duly subpoenaed or bound by recognizance to attend to give evidence, as the case may be) and has not shown before me any sufficient excuse for his default;

Wherefore I adjudge the defaulter for his said default, (set out punishment as authorized and determined in accordance with section 708 of theCriminal Code ).

Dated this day of A.D. , at .

A Justice or Clerk of the Court

(Seal, if required)