C.A. C. No.

NOVA SCOTIA COURT OF APPEAL

BETWEEN:

                                                                                                 Appellant

- and -

                                Her Majesty the Queen

                                                                                                 Respondent

AFFIDAVIT

I, _____________________ , of _________________, Nova Scotia, hereby make oath and say as follows:

1. THAT I am the Appellant on this appeal and make this Affidavit in support of my motion for the appointment of legal counsel pursuant to section 684 of the Criminal Code of Canada.

2. THAT

3. THAT

include as many additional paragraphs as required.

SWORN TO at Halifax, in the Halifax )

Regional Municipality, Province of Nova )

Scotia, this day of _____, 20 ___ )

                                                                )

                                                                )

                                                                 )

                                                                 )

______________________________ _____________________________

Commissioner of Oaths Appellant