Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of

(territorial division)

To (name of financial institution, person or entity), of :

Whereas I am satisfied by information on oath of (name of peace officer or public officer), of , that there are 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) and that (specify the data) is in your possession or control and will assist in the investigation of the offence;

Therefore, you are ordered to prepare and produce a document setting out (specify the data) that is in your possession or control when you receive this order.

The document must be produced to (name of the peace officer or public officer) within (time) at (place) in (form).

This order is subject to the following conditions:

You have the right to apply to revoke or vary this order.

If you contravene this order without lawful excuse, you may be subject to a fine, to imprisonment or to both.

Dated (date), at (place).

(Signature of justice or judge)