On or about the _______day of _______, in the__________ District of ______,
JOHN DOE, defendant herein, knowingly and fraudulently made a material false statement under the penalty of perjury, as permitted under Section 1746 of Title 28, in and in relation to a case under Title 11, In re John Doe, No. __________, by submitting a voluntary petition under Chapter 13 of Title 11 in which the defendant fraudulently left the question "pending bankruptcy case filed within last six years (if more than one attach additional sheets)" blank, then well knowing that he had filed four previous bankruptcy cases within the past six years.
All in violation of Title 18, U.S.C. § 152(3).
[cited in USAM 9-41.001]