Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of

(territorial division)

To (name of person), of , born on (date of birth):

Because on (date) at (hour) at (place) a sentence was imposed on you — or a verdict of not criminally responsible on account of mental disorder was rendered in respect of you — for a primary offence and the court did not, at the time the sentence was imposed or the verdict was rendered, consider whether an order to comply with the Sex Offender Information Registration Act should be made under any of subsections 490.012(1) to (3) of the Criminal Code;

You are ordered, in His Majesty’s name, to appear on (date) at (hour) at (place) for the purposes of considering whether an order should be made under any of subsections 490.012(1) to (3) of the Criminal Code in respect of the primary offence for which the sentence was imposed or the verdict of not criminally responsible on account of mental disorder was rendered.

You are warned that, unless you have a lawful excuse, it is an offence under subsection 145(3) of the Criminal Code to fail to appear as required in this summons.

If you commit an offence under subsection 145(3) of the Criminal Code, a warrant for your arrest may be issued (section 512 or 512.1 of the Criminal Code) and you may be liable to a fine or to imprisonment, or to both.

Signed on (date), at (place).

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

(Name of the judge or justice)