Court File No.___________

PROVINCIAL COURT
(SPECIFY COURT LOCATION)
(Criminal Division)

BETWEEN:

HER MAJESTY THE QUEEN

-and-

(SPECIFY NAME OF ACCUSED)



AFFIDAVIT OF (name)



	I, (full name of affiant, of the (City, Town, etc.) of ____________, in the Province of ________________ (set out the affiants capacity), MAKE OATH AND SAY (or AFFIRM):

	1.	(Set out the statements of fact in consecutively numbered paragraphs, with each paragraph being confined as far as possible to a particular statement of fact.)



SWORN (or affirmed) before me at the (City, Town, etc.) of _________________ in the Province of _______________ on ___________________ (date).



Commissioner for Taking Oaths (or as may be)
)
)
)
)
)
)
)
)




______________________________
(affiant’s signature)