Criminal Code

Canada,

Province of ,

(territorial division).

To the justice who issued a warrant to the undersigned under section 320.29, 487 or 487.1 of the Criminal Code (or another justice for the same territorial division or, if no warrant was issued, any justice having jurisdiction in respect of the matter).

I, (name of the peace officer or other person) have (state here whether you have acted under a warrant issued under section 320.29, 487 or 487.1 of theCriminal Codeor under section 489 of theCriminal Codeor otherwise in the execution of duties under theCriminal Codeor other Act of Parliament to be specified)

• 1 searched the premises situated at ; and

• 2 seized the following things and dealt with them as follows:

  Property Seized (describe each thing seized)	Disposition (state, in respect of each thing seized, whether (a) it was returned to the person lawfully entitled to its possession, in which case the receipt for it shall be attached to this report; or (b) it is being detained to be dealt with according to law, in which case indicate the location and manner in which or, if applicable, the person by whom, it is being detained.)
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In the case of a warrant issued by telephone or other means of telecommunication, the statements referred to in subsection 487.1(9) of the Criminal Code shall be specified in the report.

Dated (date), at (place).

Signature of the peace officer or other person