- 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 said District entitled ______________ v. _________, No. __________, knowingly made a material declaration which was inconsistent with a prior material declaration made by RICHARD ROE while testifying under oath in a proceeding before a duly empaneled and sworn grand jury for the United States District Court for the ____________________ District of _______________, such material declarations being inconsistent to the degree that one of them is necessarily false.
- It was material to each of the proceedings described in paragraph 1 to determine whether John Doe had made a loan of money to the said Richard Roe at anytime.
- The said RICHARD ROE on or about the __________ day of ________, 19__, while under oath as a witness in ____________ v. ___________, No. _______________, knowingly testified with respect to a material matter as follows:
- "Q. Have you ever to your knowledge received a loan of money from John Doe? A. No."
- The said RICHARD ROE, on or about the _________ day of ________, 19__, while appearing as a witness under oath before the federal grand jury in the ______________ District of ___________, knowingly testified with respect to a material matter as follows:
- "Q. Have you ever to your knowledge received a loan of money from John Doe? A. Yes."
- The underscored material declarations of the said RICHARD ROE quoted in paragraph 3 and 4 herein were irreconcilably contradictory and were material to the point in question in each of the proceedings before which such declarations were made.All in violation of 18 U.S.C. § 1623.
[cited in USAM 9-69.200]