Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of

(territorial division)

This is the information of (name of peace officer or public officer), of (“the informant”).

The informant says that they have reasonable grounds to suspect that an offence has been or will be committed under (specify the provision of the Criminal Code or other Act of Parliament) and that keeping (specify the account) open or active will assist in the investigation of the offence.

The reasonable grounds are:

The informant therefore requests that (name of the person) be ordered to keep (specify the account) open or active for 60 days after the day on which the order is made.

Sworn before me on (date), at (place).

(Signature of informant)

(Signature of justice or judge)