Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of

(territorial division)

To the peace officers in the said (territorial division) and to the keeper (administrator, warden) of the (prison, hospital or other appropriate place where the accused is detained).

This warrant is issued for the committal of A.B., of , (occupation), hereinafter called the accused.

Whereas the accused has been charged that (set out briefly the offence in respect of which the accused was charged);

And whereas the accused was foundFootnote ^*

• ☐ unfit to stand trial

• ☐ not criminally responsible on account of mental disorder

And whereas the Review Board has held a hearing and decided that the accused shall be detained in custody;

And whereas the accused is required to be detained in custody pursuant to a warrant of committal issued by (set out the name of the Judge, Clerk of the Court, Provincial Court Judge or Justice as well as the name of the court and territorial division), dated the day of , in respect of the offence that (set out briefly the offence in respect of which the accused was charged or convicted);

This is, therefore, to command you, in Her Majesty’s name, toFootnote ^*

• ☐ execute the warrant of committal issued by the court, according to its terms

• ☐ execute the warrant of committal issued herewith by the Review Board

• Return to footnote ^*Check applicable option.

Dated this day of A.D. , at .

(Signature of chairperson of the Review Board)