Rules of the Supreme Court of Canada

I (name), (counsel or agent) for the appellant, hereby certify that the annexed record contains the judgment appealed from and only so much of the pleadings, evidence, affidavits and other documents as is necessary to raise the question for the decision of the Court and that all recorded reasons for judgments and orders are included in the said record.

And I do further certify that I have closely examined the record and verily believe that it is a true and correct reproduction of the originals and that the same has been proofread.

Dated at (place and province or territory) this (date) day of (month), (year).

(Counsel or agent) for the appellant

(Signed)