CANADA

PROVINCE OF NOVA SCOTIA [CR # ]

HALIFAX REGIONAL MUNICIPALITY

IN THE SUPREME COURT OF NOVA SCOTIA

APPLICATION TO RENDER BY SURETY

Order sought to be relieved from is attached

I, ______________________________________________________________

                                              name of surety

of _______________________________________________being the surety for

                                        address/telephone number

______________________________________________ who is bound by a Recognizance

                                                    name of accused

to appear before the Supreme Court of Nova Scotia, 1815 Upper Water Street, Halifax, Nova

Scotia, on ________________________________, hereby apply to be relieved of the

obligation

under Section 766(1) of the Criminal Code of Canada,

This request to be relieved of this obligation will be heard before a Justice of the Supreme

Court at Criminal Crownside ________ day of _________________________, A.D. 20 .

DATED at Halifax, Province of Nova Scotia, this _____ day ____________ of A.D.20 .

                                                                  _________________________________________

                                                                  SIGNATURE OF SURETY

                                                                   _ ________________________________________

                                                                    ADDRESS

                                                                    _________________________________________

                                                                    TELEPHONE NUMBER

C.C. Provincial Crown Fax 424-0658

           -or-

           Federal Crown Fax 426-7274