Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of ,

(territorial division).

To the peace officers in the said (territorial division):

Whereas A.B., of hereinafter called the accused, has been charged that (state place of offence and charge);

And whereas the deposition of X.Y. in respect of the charge has been taken by me (or if the signatory is not the justice, the justice);

And Whereas the charge is for an offence committed in the (territorial division);

This is to command you, in Her Majesty’s name, to convey the said A.B., before a justice of the (last mentioned territorial division).

Dated (date), at (place).

(Signature of justice or clerk of the court)