Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of ,

(territorial division).

In the (set out name of the court)

Her Majesty the Queen

against

(name of accused)

(Name of accused) stands charged

• 1 That he (state offence).

• 2 That he (state offence).

Dated this day of A.D. , at .

(Signature of signing officer, Agent of Attorney General, etc., as the case may be)

Note: The date of birth of the accused may be mentioned on the information or indictment.