- On or about the _____ day of _______________, 19__, in the _________________ District of _______________, RICHARD ROE, while under oath as a witness in a case then being tried before the United States District Court for the said District entitled, ____________ v. _____________, No. _________, knowingly did make a false material declaration, that is to say:
- At the time and place aforesaid, the Court and Jury were engaged in the trial of the aforementioned case wherein John Doe, the defendant therein, was charged with making an extortionate extension of credit to RICHARD ROE. It was a matter material to said trial to determine whether or not John Doe had ever made a loan of money in any amount to Richard Roe.
- At the time and place alleged, RICHARD ROE, while under oath, did knowingly declare before said Court and Jury with respect to the aforesaid material matter, as follows:
- "Q. Have you ever to your knowledge received a loan of money from John Doe? A. No."
- The aforesaid underscored testimony of RICHARD ROE, as he then and there well knew and believed, was false in that, on or about _________________, RICHARD ROE did receive a loan of money from John Doe.
All in violation of 18 U.S.C. § 1623.
[cited in JM 9-69.200]