IN THE PROVINCIAL COURT OF NOVA SCOTIA

APPLICATION TO VARY CONDITIONS OF RECOGNIZANCE


My name is:  __________________________________________________


I am the defendant in case number ________________________ and I hereby apply

to the court to have the following condition(s) of the recognizance varied:



Condition(s) to be changed:  

(Mark “x” in the applicable box)


A  (    )  Residence  - I am required to reside at: _____________________________


            ______________________________________________________________


B  (     ) I am required to remain in Nova Scotia.



C  (     ) No Contact:  - I am not permitted any contact with:


            ______________________________________________________________

D  (     ) Curfew - I am required to be in my residence from ___p.m. until ___ a.m.

E  (      ) House arrest

F  (      ) Other condition: _______________________________________________


             _____________________________________________________________


I wish the above marked condition(s) changed to:

(Mark “x” in the applicable box)


A  (     )  Residence  - I wish to reside at: _______________________________


              ____________________________________________________________


B  (     ) I wish to delete the requirement that I am  to remain in Nova Scotia.



C  (     ) No Contact:  - I wish to have contact with____________________________

            Subject to her/his consent, to be given in advance.

D  (     ) I wish to have the Curfew deleted, OR,

   (     ) I wish to have the curfew amended to require me to be in my home

             From ____ p.m. until ____ a.m.

E  (      ) House arrest - I wish to change the terms of house arrest as follows:

             ______________________________________________________________

            ______________________________________________________________

            ______________________________________________________________


F  (      )  I wish to have the Other condition changed as follows:


              _____________________________________________________________


              _____________________________________________________________


              _____________________________________________________________


              _____________________________________________________________


I make this request due to the following changes in circumstances:

(Provide your reasons for the application.  You should give information about circumstances that have arisen, or that have changed since the date of your recognizance.  Attach a separate page if needed)


______________________________________________________________________


______________________________________________________________________


______________________________________________________________________


______________________________________________________________________


______________________________________________________________________


______________________________________________________________________



Contact information  for the Defendant


My address is: _________________________________________________________


                    __________________________________________________________


My phone number is:  ___________________________________________________


Date signed:    ________________________________________________, 201____.      


My signature:   _________________________________________________________




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