Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of ,

(territorial division).

To the keeper of the (prison) at :

Whereas by warrant dated (date), A.B., in this order called the accused, was committed to your custody and you were required to keep them safely until the (date), and then to have them before me or any other justice (or if the signatory is not the justice, any justice) at (place) at (hour) to answer to the charge against the accused and to be dealt with according to law unless you should be ordered otherwise before that time;

Now, therefore, you are directed to have the accused before at (place) at (hour) to answer to the charge against them and so they may be dealt with according to law.

Dated (date), at (place).

(Signature of justice or clerk of the court)