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Whereas E.F. of ................, hereinafter called the defaulter, was on the ................ day of ................ A.D. ........, at ................., convicted before ................ for contempt in that he did not attend before ................ to give evidence on the trial of a charge that (state offence as in the information) against A.B. of ................, although (duly subpoenaed or bound by recognizance to appear and give evidence in that behalf, as the case may be) and did not show any sufficient excuse for his default;