FORM 4 (Sections 566, 566.1, 580 and 591)
Heading of Indictment
Canada,
Province of ,
(territorial division).
In the (set out name of the court)
Her Majesty the Queen
against
(name of accused)
(Name of accused) stands charged
1 That he (state offence).
2 That he (state offence).
Dated this day of A.D. , at .
(Signature of signing officer, Agent of Attorney General, etc., as the case may be)
Note: The date of birth of the accused may be mentioned on the information or indictment.