Criminal Code

Canada, Province of , (territorial division).

I, A.B., of , (occupation), understand that it is alleged that I have committed (set out substance of the offence).

In order that I may be released from custody by way of (a promise to appear or a recognizance), I undertake to (insert any conditions that are directed):

• (a) remain within (designated territorial jurisdiction);

• (b) notify (name of peace officer or other person designated) of any change in my address, employment or occupation;

• (c) abstain from communicating, directly or indirectly, with (identification of victim, witness or other person) or from going to (name or description of place) except in accordance with the following conditions: (as the peace officer or other person designated specifies);

• (d) deposit my passport with (name of peace officer or other person designated);

• (e) to abstain from possessing a firearm and to surrender to (name of peace officer or other person designated) any firearm in my possession and any authorization, licence or registration certificate or other document enabling the acquisition or possession of a firearm;

• (f) report at (state times) to (name of peace officer or other person designated);

• (g) to abstain from

  • (i) the consumption of alcohol or other intoxicating substances, or

  • (ii) the consumption of drugs except in accordance with a medical prescription; and

• (h) comply with any other conditions that the peace officer or officer in charge considers necessary to ensure the safety and security of any victim of or witness to the offence.

I understand that I am not required to give an undertaking to abide by the conditions specified above, but that if I do not, I may be kept in custody and brought before a justice so that the prosecutor may be given a reasonable opportunity to show cause why I should not be released on giving an undertaking without conditions.

I understand that if I give an undertaking to abide by the conditions specified above, then I may apply, at any time before I appear, or when I appear, before a justice pursuant to (a promise to appear or a recognizance entered into before an officer in charge or another peace officer), to have this undertaking vacated or varied and that my application will be considered as if I were before a justice pursuant to section 515 of the Criminal Code.

I also understand that this undertaking remains in effect until it is vacated or varied.

I also understand that failure without lawful excuse to abide by any of the conditions specified above is an offence under subsection 145(5.1) of the Criminal Code.

Subsection 145(5.1) of the Criminal Code states as follows:

• “(5.1) Every person who, without lawful excuse, the proof of which lies on the person, fails to comply with any condition of an undertaking entered into pursuant to subsection 499(2) or 503(2.1)

  • (a) is guilty of an indictable offence and is liable to imprisonment for a term not exceeding two years; or

  • (b) is guilty of an offence punishable on summary conviction.”

Dated this day of A.D. , at .

(Signature of accused)