Criminal Code (R.S.C., 1985, c. C-46)

Canada

Province of

(territorial division)

• [ ] To (name of judge), a judge of the provincial court who issued a warrant under section 487.05 or granted an authorization under section 487.055 or 487.091 of the Criminal Code or to another judge of that court:

• [ ] To the court that made an order under section 487.051 of the Criminal Code:

I (name of peace officer), declare that (state here whether the samples were taken under a warrant issued under section 487.05, an order made under section 487.051 or an authorization granted under section 487.055 or 487.091 of theCriminal Code ).

I have (state here whether you took the samples yourself or caused them to be taken under your direction) from (name of offender) the number of samples of bodily substances that I believe is reasonably required for forensic DNA analysis, in accordance with (state whether the samples were taken under a warrant issued or an authorization granted by the judge or another judge of the court or an order made by the court).

The samples were taken on the day of , A.D. , at o’clock.

I (or state the name of the person who took the samples) took the following samples from (name of offender) in accordance with subsection 487.06(1) of the Criminal Code and was able, by virtue of training or experience, to do so (check applicable box):

• [ ] individual hairs, including the root sheath

• [ ] epithelial cells taken by swabbing the lips, tongue or inside cheeks of the mouth

• [ ] blood taken by pricking the skin surface with a sterile lancet

Any terms or conditions in the (warrant, order or authorization) have been complied with.

Dated this day of A.D. , at .

(Signature of peace officer)