Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of ,

(territorial division).

• 1 Identification

  Surname: Given name(s):

  Date of Birth:

  Home address:

  Phone number(s): (primary) (other)

  Other contact information (if any):

  Employment or occupation (if any):

  Name and contact information for employer (if any):

• 2 Information about the Accused

  Surname: Given name(s):

  Date of Birth:

  Court file number:

• 3 Other information required

  Relationship to the accused:

  I am acting as a surety in respect of another accused.

  □ Yes □ No

  If yes, name and date of birth of any other accused:

  I have a criminal record or there are outstanding criminal charges against me.

  □ Yes □ No

  If yes, description of criminal record, if any, and all outstanding criminal charges, specifying offence and year of conviction:

• 4 Charges against the Accused

  I understand that the accused has been charged with (set out briefly the offence in respect of which the accused was charged).

• 5 Other Outstanding Charges against the Accused

  □ I understand that the accused does not have any other outstanding criminal charges.

  □ I understand that the accused has also been charged with (set out briefly the offence in respect of which the accused was charged), but this declaration does not apply to those charges.

• 6 Criminal Record of the Accused

  □ I understand that the accused does not have a criminal record.

  □ I understand that the accused has a criminal record, which is described below or a copy of which I have attached and initialled.

  

• 7 Financial Promise or Deposit

  As a surety for the accused, I am willing to (promise or deposit) to the court the amount of

• 8 Acknowledgment

  I understand that failure on the part of the accused to follow any of the conditions in their release order or recognizance could lead to the forfeiture of the amount of money that has been promised or deposited.

  I understand that I may, at any time, ask to no longer be a surety by making an application, by bringing the accused to the court in order to be discharged from my obligation (section 767 of the Criminal Code) or by taking and giving the accused into custody (section 768 of the Criminal Code).

  I voluntarily make this declaration and it is my free choice to take on the responsibilities of a surety.

• 9 Signature

  Signed on (date), at (place).

  

  (Signature of the surety)

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

  

  (Signature of the person who is authorized to take or receive statements made under oath, solemn declaration or solemn affirmation)