Criminal Code

Canada,

Province of ,

(territorial division).

To the peace officers in the said (territorial division):

Whereas A.B., of hereinafter called the accused, has been charged that (state place of offence and charge);

And Whereas I have taken the deposition of X.Y. in respect of the said charge;

And Whereas the charge is for an offence committed in the (territorial division);

This is to command you, in Her Majesty’s name, to convey the said A.B., before a justice of the (last mentioned territorial division).

Dated this day of A.D. , at .

A Justice of the Peace in and for