IN THE COUNTY COURT

OF VICTORIA
AT MELBOURNE CR-____-______

BETWEEN

Prosecution
and

Accused

AFFIDAVIT

Date of Document: Solicitors Code:

Filed on behalf of: Telephone:

Prepared by: DX:

Ref:

I, of
make oath and state that :

Sworn at , in the State of Victoria

this day of 20 /

Before me,