"In that_____________________did, (at) (on board)_____________________, on or about
_____________________19__, [(in affidavit) (in_____________________)] wrongfully and unlawfully (make) (subscribe) under lawful (oath) (affirmation) a false statement in substance as follows:_____________________, which statement he/she did not then believe to be true."
"Oath" means a formal pledge, coupled with an appeal to a Supreme Being, that the truth will be stated;
"Affirmation" means a solemn and formal pledge, binding upon a person's own conscience that the truth will be stated;
"Subscribe" means to write one's own name on a document for the purpose of adopting its words as one's own expressions.
Haw. Code R. § 7-9-15