FORM 4D

AFFIDAVIT

(General Heading — Form 4A or 4B)

AFFIDAVIT OF (name)

I, (full name of deponent), of the (City, Town, etc.) of ,

in the Province of (where the deponent is a party or the lawyer, officer, director, partner, proprietor, member or employee of a party, set out the deponent's capacity), MAKE OATH AND SAY (or AFFIRM):

1.	(Set out the statements of fact in consecutively numbered paragraphs, with each paragraph being confined as far as possible to a particular statement of fact).

SWORN (or Affirmed) before me	)

in the (City, Town, etc.) of	)

, in the	)

Province of ,	)

on (date).	)	(signature of deponent)

)

)

Commissioner for Oaths	)

(or as may be)