- 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:
- 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.
- 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.
- 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]