Criminal Code

Canada,

Province of

(territorial division)

To A.B., of , (occupation), (address or address of court if no fixed address), (date of birth), (gender):

You have been convicted of or found not criminally responsible on account of mental disorder for (description of offence(s)) under (applicable designated offence provision(s) of theCriminal Code), a designated offence (or designated offences) within the meaning of subsection 490.011(1) of the Criminal Code.

• 1 You must report for the first time to the registration centre referred to in section 7.1 of the Sex Offender Information Registration Act, whenever required under subsection 4(1) of that Act.

• 2 You must subsequently report to the registration centre referred to in section 7.1 of the Sex Offender Information Registration Act, whenever required under section 4.1 or 4.3 of that Act, for a period of years after this order is made (or if paragraph 490.013(2)(c) or any of subsections 490.013(3), (5) or (6) of the Criminal Code applies, for life).

• 3 Information relating to you will be collected under sections 5 and 6 of the Sex Offender Information Registration Act by a person who collects information at the registration centre.

• 4 Information relating to you will be registered in a database, and may be consulted, disclosed and used in the circumstances set out in the Sex Offender Information Registration Act.

• 5 If you believe that the information registered in the database contains an error or omission, you may ask a person who collects information at the registration centre referred to in section 7.1 of the Sex Offender Information Registration Act or, if applicable, the Canadian Forces Provost Marshal, to correct the information.

• 6 You have the right to apply to a court to terminate this order, and the right to appeal the decision of that court.

• 7 If you are found to have contravened this order, you may be subject to a fine or imprisonment, or to both.

• 8 If you are found to have provided false or misleading information, you may be subject to a fine or imprisonment, or to both.

Dated this day of , at .

(Signature of judge or clerk and name of court)

(Signature of person subject to order)