Canada,

Province of

(territorial division)

This is the information of (name of peace officer or public officer), of (“the informant”).

The informant says that on or after (insert date) the informant became aware of the following facts that justify the revocation (or variation) of an order made on (insert date) under (specify the provision of the Criminal Code):

The informant therefore requests that the order be revoked (or be varied as follows: ).

Sworn before me on (date), at (place).

(Signature of informant)

(Signature of justice or judge)