On or about the______day of ____ , in the_________District of_______, defendant JOHN DOE, with intent to deceive, falsely did represent that his social security number was __________ on a bankruptcy petition, Case No. __________, then well knowing that social security number _________ had not been assigned to him by the Secretary or other proper authority.
All in violation of 42 U.S.C. § 408(a)(7)(B).
[cited in USAM 9-41.001]