An indictment for obtaining credit, loan, etc., by false statement in writing, shall be sufficient if it be in form, tenor or effect as follows (after following the form in section one):
That A ……………, on the …….. day of …….., nineteen …….., in the said county of …….., and within one year before the finding of this indictment, with intent to cheat and defraud B …….., then and there knowingly, unlawfully, designedly and falsely did make a certain statement in writing (or cause the same writing be relied upon, which said statement in writing was as follows to be made, as the case may be), with intent that the said statement in (here copy, or set forth the full intent and meaning of said statement in writing), (or state that he made said writing on behalf of any person, firm, or corporation in whom or in which he was interested), and which said statement was with respect to the financial condition, means and ability of himself (or of the person, firm or corporation in whom or which he was interested or for whom he was acting), by which false, unlawful and designed statement in writing, he the said A ……………, did obtain from the said B …………… a certain (here state what the credit obtained was, such as the extension of credit, or the making of a loan, discount of account receivable, indorsement of the note, etc., as the case may be), which said statement in writing the said A …………… then and there knew to be false and untrue, and which said false statement was relied on by the said B ……………, by reason of which the said A ……………did obtain from the said B …………… the (here describe the credit or other thing obtained), unlawfully, against the peace and dignity of the state.