Canada IN THE PROVINCIAL COURT NS Form 3/2
Province of Nova Scotia
Revised 10/20
INFORMATION
(Sec. 810 CC)
This is the Information of
(name of Informant)
Date of Birth:
of
(address)
(telephone numbers) (e-mail address)
Nova Scotia, made: personally as Complainant, or by or on behalf of
(Complainant).
What is the Complainant’s relationship to the Defendant?
The Informant says that
(name of Defendant)
of
(address)
(telephone numbers) (e-mail address)
at
(place of incident)
Nova Scotia, on or about / between , 20_____,
and , 20_____, did:
by uttering the words
by the Defendant’s action
cause the Complainant to fear that the Defendant will cause:
personal injury to the Complainant
personal injury to the Complaint’s spouse
(name of spouse)
personal injury to the Complaint’s child(ren)
(name of child/children)
damage to Complainant’s property located at
(address)
The Informant, therefore, prays that the Defendant be ordered to enter into a RECOGNIZANCE (Peace
Bond) with, or without sureties, to keep the peace and be of good behaviour for any period not to exceed
12 months, and comply with any other reasonable conditions prescribed in the RECOGNIZANCE as the
Court considers desirable for securing the good conduct of the Defendant, or commit the Defendant to
prison for a term not exceeding 12 months if the Defendant fails or refuses to enter into the Recognizance,
pursuant to Section 810 of the Criminal Code.
SWORN or Solemnly Affirmed before me at
, Nova Scotia,
on , 20____,
by the Informant, who being unable to write their name,
verbally indicated their understanding of this Information.
Justice of the Peace
