Criminal Code

Canada,

Province of ,

(territorial division).

Be it remembered that on (date), at (place) in the (territorial division), E.F. of , in this conviction called the defaulter, is convicted for contempt in that they 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 any sufficient excuse for their default;

The defaulter is therefore convicted for their default, (set out punishment as authorized and determined in accordance with section 708 of theCriminal Code).

Dated (date), at (place).

(Signature of judge, provincial court judge, justice or clerk of the court)

(Seal, if required)