This is the information of Police Constable   (name),
a Peace Officer (the “informant”) of the  
Police Department. The informant says that he has reasonable and
probable grounds to believe and does believe that

Count 1
  (suspect)  , on or about the   day of   ,
2004, at or near the City of   , in the Province of
  , did, without lawful authority and knowing
that another person was harassed or was reckless as to whether the
other person was harassed, engage in conduct that caused that other
person,  (victim)   , to reasonably fear for his/her
safety or the safety of anyone known to   (him/her)  , contrary to
Section 264 of the Criminal Code.