District No.

.......... Prosecutor

.......... Offender

THE INFORMATION of ........ of ........ who says on oath:-

On the ... day of ..... 19 ..... at a sitting of the District Court held at ............ the above-named ........ of .......... entered into a recognisance pursuant to section 28 (2) of the Misuse of Drugs Act, 1977 in the sum of £...

*(together with .......... of ......... and .......... of ........... sureties in the sum of £ ...... each) conditioned that the said ............

*(a) would be under the supervision of ........ during the period of ................. from the date of the recognisance, and would receive visits from and permit visits by the said ...................... *(at the Principal Party's residence) *(at .................. ) as follows:-..............;

*(b) would undergo medical or other treatment recommended in the report made by .................

*(c) would, for the treatment referred to at condition (b) above, *(attend) *(remain) in the hospital, clinic or other place at ......... for the period of ...........

*(d) would attend the following course of education, instruction or training:

.............

I say that the said ............. has failed to observe the condition(s) of the said recognisance inasmuch as

and thereby is in breach of the recognisance.

Signed ......................

Informant

SWORN before me this ... day of ...... 19...

Signed ................

Judge of the District Court.

* Delete where inapplicable