District No.

............. Prosecutor

............. Offender

............. *Surety

............. *Surety

WHEREAS IT APPEARS from an information in writing sworn on the ... day of ....... 19.... by .......... of .......... that a recognisance pursuant to section 28 (2) (a) of the Misuse of Drugs Act 1977 was entered into before the Court on the .... day of ...... 19... by you .......... the above-named offender (Principal Party) in the sum of £....

*(by you .......... Surety, in the sum of £ ... ,) and

*(by you .......... Surety, in the sum of £... ,)

conditioned that the principal party

*(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 his/her 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, ..........

AND WHEREAS complaint was made in the said information that you, the said offender and principal party to the said recognisance, did fail to observe the said conditions) in that you failed to

THIS IS TO COMMAND YOU, the said offender *(and you the said surety/sureties) to appear at the sitting of the District Court to be held at ........... on the ... day of ...... 19.... at ... a.m./p.m. on the hearing of that complaint.

Dated this day of 19.

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

Judge of the District Court.

To

of , the above-named offender.

*To

of , Surety

*To

of , Surety

* Delete where inapplicable