UJI 14-1647. Insurance; false or fraudulent account; essential elements.

For you to find the defendant guilty of making preparing, making or signing a false or fraudulent account, [as charged in Count ________]1, the state must prove to your satisfaction beyond a reasonable doubt each of the following elements of the crime: 1. The defendant prepared, made or signed a false or fraudulent [account,]2 [certificate,] [affidavit] [proof of loss] [or] [__________________ (other document)]; 2. The defendant intended that the [account,]2 [certificate,] [affidavit] [proof of loss] [or] [_________________ (other document)] be presented or used in support of a claim for payment of a loss under an insurance policy; 3. The defendant [knew the statement to be untrue]2 [acted with reckless disregard of the truth]; 4. This happened in New Mexico on or about the ______ day of __________________, ______.