Criminal Code

Canada,

Province of ,

(territorial division).

To the justice who issued a warrant to the undersigned pursuant to section 256, 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 pursuant to section 256, 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 therefor shall be attached hereto, or (b) it is being detained to be dealt with according to law, and the location and manner in which, or where 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 this day of A.D. , at .

Signature of peace officer or other person