ARCHIVED — Vol. 146, No. 5 — February 29, 2012

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Form 4 / AFFIDAVIT

Court File No.

COURT OF ONTARIO
(Superior Court of Justice)
((specify) Region)

BETWEEN:

HER MAJESTY THE QUEEN

—and—

specify name of accused)

AFFIDAVIT OF (name)
(Criminal Proceedings Rules, Rule 4, Form 4)

I, (full name of deponent), of the (City, Town, etc.) of __________, in the (County, District, Regional Municipality, etc.), (set out the deponent’s 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 (County, District, Regional Municipality, etc.) of __________________ on (date), 2____.

________________________________

(Deponent’s signature)

________________________________

Commissioner for Taking Oaths
(or as may be)