Criminal Code

Canada,

Province of ,

(territorial division).

To a justice having jurisdiction in respect of the matter and jurisdiction in the province in which the warrant referred to below was issued (or, if no warrant was issued, a 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 the Criminal Code, under section 487.11 or 489 of the Criminal Code, or otherwise in the execution of duties under the Criminal Code or 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:

  Thing 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.)
  1.
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Signed on (date), at (place).

(Signature of peace officer or other person)