Document ID: chunk:federal_register_of_legislation:F2021C00429:clause:1_4
Version: federal_register_of_legislation:F2021C00429
Segment Type: clause
Provision Reference: sch 1 cl 4
Character Range: 92861–93817

4

   1 insert State or Territory
   2 insert name of prison or hospital
   3 insert full name of prescribed authority
   4 insert designation of prescribed authority
   5 insert full name of person
   6 insert time and date
   7 insert address of court
   8 insert date
   9 signature of prescribed authority
   * omit if inapplicable

Form 19—Summons in relation to breach of psychiatric probation order or program probation order

Commonwealth of Australia

Crimes Act 1914

SUMMONS UNDER PARAGRAPH 20BW(1)(a)

IN THE 1

AT 2

IN THE *STATE OF 3
4(Informant)
‑and‑
5(Defendant)
To: 6
You are summoned under paragraph 20BW(1)(a) of the Crimes Act 1914 to appear before the              7 at              8 at              9 to answer the information alleging the breach of the following *condition/*conditions of the order under section *20BV/*20BY of that Act:
      (a)  10;
      (b)  10;
and to be further dealt with according to law.
Dated 11.
12