Full text
Be it remembered that on the ................ day of ................ A.D. ........, at ................ in the (territorial division), E.F. of ................, hereinafter called the defaulter, is convicted by me for contempt in that he did not attend before (set out court or justice) to give evidence on the trial of a charge that (state fully offence with which accused was charged), although (duly subpoenaed or bound by recognizance to attend to give evidence, as the case may be) and has not shown before me any sufficient excuse for his default;