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 believe that the disclosure of the existence (or any of the contents or any of the following portion or portions) of (identify the preservation demand made under section 487.012 of the Criminal Code or the order made under any of sections 487.013 to 487.018 of that Act, as the case may be) during (identify the period) would jeopardize the conduct of the investigation of the offence to which it relates:

(specify portion or portions)

The reasonable grounds are:

The informant therefore requests an order prohibiting (name of the person, financial institution or entity) from disclosing the existence (or any of the contents or any of the specified portion or portions) of the demand (or the order) during a period of (identify the period) after the day on which the order is made.

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

(Signature of informant)

(Signature of justice or judge)