Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of ,

(territorial division).

To the peace officers of (territorial division) and to the keeper of the (prison) at :

Whereas it appears that on the hearing of an appeal before the (set out court) it was adjudged that A.B., of , hereinafter called the defaulter, should pay to the Clerk of the Court the sum of dollars in respect of costs;

And Whereas the Clerk of the Court has certified that the defaulter has not paid the sum within the time limited therefor;

I do hereby command you, the said peace officers, in Her Majesty’s name, to take the defaulter and safely convey him to the (prison) at and deliver him to the keeper thereof, together with the following precept:

I do hereby command you, the said keeper, to receive the defaulter into your custody in the said prison and imprison him for the term of , unless the said sum and the costs and charges of the committal and of conveying the defaulter to the said prison are sooner paid, and for so doing this is a sufficient warrant.

Dated this day of A.D. , at .

A Justice of the Peace in and for