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U.S. Attorneys' Manual

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U.S. Attorneys' Manual
Criminal Resource Manual

1763. Perjury Cases -- Sample Indictment -- 18 USC 1621 (Second Paragraph)

  1. On or about the ______ day of ____________, 19__, in the __________________ District of __________________, JOHN DOE, did submit a material written application for a license from the _________ Department, executed under penalty of perjury under the format of 28 U.S.C. § 1746, in which he did willfully and knowingly state material matter which he did not believe to be true, that is to say:
  2. At the time and place aforesaid the ___________ Department, did require that applications for licenses granted by it be in writing and executed in the format provided by 28 U.S.C. § 1746. It was material to such license application that the applicants state if they had ever applied for such a license in the past.
  3. At the time and place aforesaid, JOHN DOE, submitted a signed written application for a license to the _____________ Department, which contained the following statement: "I declare under penalty of perjury that the forgoing is true and correct. Executed on _________. Signature ________________." The application signed and submitted by JOHN DOE, did falsely state that he had never made such an application in the past.
  4. The aforesaid statement in the application signed and submitted by JOHN DOE, as he then and there well knew and believed, was false in that on or about ______________, 19__, JOHN DOE, did submit an application to the ________________ Department for a license.

All in violation of 18 U.S.C. § 1621.

[cited in USAM 9-69.200]