"In that _____________________, having taken a lawful oath [in a proceeding before (a board of officers) (a court of inquiry) concerning _____________________] [upon the making of an affidavit as to _____________________] [_____________________], a case in which a law of the United States authorized an oath to be administered, that [he/she, then said _____________________, would (testify) (declare) (depose) (certify) truly] [a written (declaration) (deposition) (certificate) subscribed by him/her was true], did _____________________, (at) (on board) , on or about _____________________ 19__, willfully and contrary to such oath (state) (subscribe) a material matter, to wit: _____________________, which matter he/she did not then believe to be true."
Haw. Code R. § 7-9-21