Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of

(territorial division)

To (name of person, financial institution 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 believe that the disclosure of the existence (or any of the contents or any of the portion or portions, specified in the information,) of (identify the preservation demand made under section 487.012 of the Criminal Code or the order made under any of sections 487.013 to 487.018 of that Act, as the case may be) during (identify the period) would jeopardize the conduct of the investigation of the offence to which it relates;

Therefore, you are prohibited from disclosing the existence (or any of the contents or any of the following portion or portions) of the demand (or the order) during a period of (identify the period) after the day on which this order is made.

(specify portion or portions)

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)