Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of

(territorial division).

To (name of person), of , born on (date of birth):

Because you have this day been charged with (set out briefly the offence in respect of which the accused is charged);

Therefore, you are ordered, in Her Majesty’s name:

• (a) to appear on (date) at (hour) at (place) for the purposes of the Identification of Criminals Act (Ignore, if not filled in); and

• (b) to attend court on (date), at (hour), at (place), or before any justice for the (territorial division) who is there, and to attend court at any time after as required by the court, in order to be dealt with according to law.

You are warned that, unless you have a lawful excuse, it is an offence under subsection 145(3) of the Criminal Code to fail to appear for the purposes of the Identification of Criminals Act or to attend court, as required in this summons.

If you commit an offence under subsection 145(3) of the Criminal Code, a warrant for your arrest may be issued (Section 512 or 512.1 of the Criminal Code) and you may be liable to a fine or to imprisonment, or to both.

If you do not comply with this summons or are charged with committing an indictable offence after it has been issued to you, this summons may be cancelled and, as a result, you may be detained in custody (Subsection 524(4) of the Criminal Code).

Signed on (date), at (place).

(Signature of judge, justice, clerk of the court or chairperson of the Review Board)

(Name of the judge, justice or chairperson)