- On or about the ______ day of __________, 19__, in the ___________________ District of ______________, JOHN DOE, while under oath and testifying in a proceeding before Grand Jury ____________, a Grand Jury of the United States in the ____________ District of ____________________, knowingly did make a false material declaration, that is to say:
- At the time and place aforesaid the grand jury was conducting an investigation to determine whether violations of Title ___________, United States Code, Section ____________ had been committed, and to identify the persons who had committed, caused the commission of, and conspired to commit such violations. It was material to the said investigation that the grand jury ascertain if JOHN DOE had ever resided in Washington, D.C.
- At the time and place alleged, JOHN DOE appearing as a witness under oath at a proceeding before the grand jury knowingly made the following declaration in response to questions with respect to the material matter alleged in paragraph III as follows:
- "Q. Have you ever lived in Washington, D.C.? A. No."
- The aforesaid underscored testimony of JOHN DOE, as he then and there well knew and believed, was false in that, on or about ________, JOHN DOE resided in Washington, D.C.
All in violation of 18 U.S.C. § 1623.
[cited in USAM 9-69.200]