Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of

(territorial division)

This is the information of (name of peace officer or public officer), of (“the informant”).

The informant says that they have reasonable grounds to suspect that an offence has been or will be committed under (specify the provision of the Criminal Code or other Act of Parliament) (or has been committed under (specify the provision of the law of the foreign state)) and that (specify the computer data) is in the possession or control of (name of the person) and will assist in the investigation of the offence.

The informant also says that a peace officer or public officer intends to apply or has applied for a warrant or order in connection with the investigation to obtain a document that contains the computer data (and, if applicable, and that (name of person or authority) is conducting the investigation and has responsibility for the investigation of such offences in (insert the name of the foreign state)).

The reasonable grounds are: (including, if applicable, whether a preservation demand was made under section 487.012 of the Criminal Code)

The informant therefore requests that (name of the person) be ordered to preserve (specify the computer data) that is in their possession or control when they receive the order for 90 days after the day on which the order is made.

Sworn before me on (date), at (place).

(Signature of informant)

(Signature of justice or judge)