______________________      V.              HER MAJESTY THE QUEEN 
Applicant/Accused                                      Respondent

_________________________________________________________________

Court File No. _________

Lower Court No. _____________

                      
                                      ONTARIO COURT OF APPEAL

                                       (proceedings commenced 

                                       (in _________________) 








                                              ---------
                                              AFFIDAVIT
                                              ---------








                                   For the Applicant: 

                                   Name: _____________________________

                                   Address: __________________________

                                   ___________________________________

                                   Tel: ______________________________

                                   Fax: ______________________________