(18 U.S.C. § 1027)
The Grand Jury Charges:
That from on or about (date) in the __________ District of ___________, in [a] document[s] required by Title I of the Employee Retirement Income Security Act of 1974 ("ERISA") to be [kept as part of the records* of][certified to the administrator** of] (name of employee welfare or pension plan) , an [employee welfare benefit plan][employee pension benefit plan], the defendant ____________ did make false statement(s) and representation(s) of fact, knowing the same to be false, and did knowingly conceal, cover up and fail to disclose facts, [the disclosure of which was required by ERISA] [which were necessary to verify, explain, clarify and check for accuracy and completeness] the (name of required report or information document) , [a report required by ERISA to be published***][information required by ERISA to be certified to the administrator], that is, (describe false entry made, facts knowingly concealed, etc.) .
All in violation of Title 18, United States Code, Sections 1027 and 2.
* See 29 U.S.C. § 1027 concerning the retention of required records.
** See 29 U.S.C. §§ 1023(a)(2) concerning the certification of information by insurance carriers, banks, organizations providing plan benefits or holding plan assets, and sponsoring employers and employee organizations.
*** See 29 U.S.C. §§ 1024(b) concerning the plan administrator's publication of annual financial reports of the plan [Form 5500 series], which are filed with the Secretary of Labor via the Internal Revenue Service, and plan descriptions.
[cited in USAM 9-136.010]