Between

A.B.

 Plaintiff

and

Her Majesty the Queen

 Defendant

STATEMENT OF CLAIM

Facts

( State with convenient certainty the facts on which the plaintiff relies as entitling the plaintiff to relief.)

Relief Sought

The plaintiff therefore claims as follows:

( a)

( b)

Dated at ................ the ................ day of ................, 20.......

( Signature)

Counsel for Plaintiff

( or the plaintiff himself or herself if the plaintiff acts for himself or herself)

R.S., 1985, c. F-7, Sch.; 2002, c. 8, s. 58.