Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of ,

(territorial division).

Be it remembered that on the day of at , A.B., (date of birth) hereinafter called the accused, was tried under Part (XIX or XXVII) of the Criminal Code on the charge that (state fully the offence of which accused was convicted), was convicted of the said offence and the following punishment was imposed on him, namely,Footnote ^*

• Return to footnote ^*Use whichever of the following forms of sentence is applicable:

• (a) that the said accused be imprisoned in the (prison) at for the term of ;

• (b) that the said accused forfeit and pay the sum of dollars to be applied according to law and also pay to the sum of dollars in respect of costs and in default of payment of the said sums forthwith (or within a time fixed, if any), to be imprisoned in the (prison) at for the term of unless the said sums and the costs and charges of the committal and of conveying the accused to the said prison are sooner paid;

• (c) that the said accused be imprisoned in the (prison) at for the term of and in addition forfeit and pay the sum of dollars to be applied according to law and also pay to the sum of dollars in respect of costs and in default of payment of the said sums forthwith (or within a time fixed, if any), to be imprisoned in the (prison) at for the term of (if sentence to be consecutive, state accordingly) unless the said sums and the costs and charges of the committal and of conveying the accused to the said prison are sooner paid.

Dated this day of A.D. , at .

Clerk of the Court, Justice or Provincial Court Judge

(Seal, if required)