Recording Requested by, And when recorded return to:

____________________________
____________________________
____________________________
____________________________

( Space above this line for recorder's use only )

Address

Private Filing Number: ____________________( create your own )

Modify this to suit your needs and send to all parties that may present a gov stance on your health..state
sec, attorney general, school etc and keep a copy for your self after notarized. Send and file this with
your local recorders office! They have a max of 30 days to respond with proof against your claim or
they have accepted your filing. Delete yellow sections rename or remove..

Affidavit of Health, Life & Status

I reserve my natural common law right not to be compelled to perform under any contract that I did not
enter into knowingly, voluntarily, and intentionally. And furthermore, I do not accept the liability
associated with the compelled and pretended "benefit"* of any hidden or unrevealed contract or
commercial agreement. As such, the hidden or unrevealed contracts that supposedly create obligations
to perform, for persons of subject status, are inapplicable to me, and are null and void. If I have
participated in any of the supposed "benefits"* associated with these hidden contracts, I have done so
under duress, for lack of any other practical alternative. Any such participation does not constitute
"acceptance" in contract law, because of the absence of full disclosure of any valid "offer," and
voluntary consent without misrepresentation or coercion, under contract law. Without a valid voluntary
offer and acceptance, knowingly entered into by both parties, there is no "meeting of the minds," and
therefore no valid contract.

Any supposed "contract" is therefore void, ab-initio. Typical examples of such compelled and
pretended "benefits"* are: 1. Birth Certificate. The fact that a birth certificate was granted to me by a
local hospital or government agency when I entered this world, is irrelevant to my Sovereignty. Social
Security Card / Number. No status, high or low, can be assigned to another person through a piece of
paper, without the recipient's full knowledge and consent. Therefore, such a piece of paper provides
only hearsay date and place information only. It indicates nothing about jurisdiction, nothing about
property ownership, nothing about rights, and nothing about subject status. The only documents that
can have any legal meaning, as it concerns my status in society, are those which I have signed as an
adult, with full knowledge and consent, free from misrepresentation or coercion of any kind. 2. The use
of an identification number from a government agency. The number normally assigned to persons of
subject status, I use exceptionally, under duress, only because of the extreme inconvenience of
operating without one in today's marketplace, where it is requested by banks, employers, lenders, and
many other government agencies and businesses. My reason for using it is not because I wish to
participate in the system, as I don't wish to participate. Let it be known that I use the number assigned
to me for information only, if at all. 3. The use of fiat currency to discharge my debts. I have used these
only because in this country, there is no other widely recognized currency. 4. The use of a bank
account, with my signature on the bank signature card. If there is any hidden contract behind the bank
signature card, my signature thereon gives no validity to it. The signature is only for verification of
identity. I can be obligated to fulfill no hidden or unrevealed contract whatsoever, due to the absence of
full disclosure and voluntary consent. Likewise, my use of the bank account thereof is due to the
absence of a bank not associated with the central bank system. In general, people have been prevented
from issuing their own currencies, and such prevention is in violation of the national constitution. Were
there an alternative, I would be happy to use it. To not use any bank at all is impossible or very
difficult, as everyone knows, in today's marketplace. 5. Past tax returns filed. Any tax returns I may
have filed in the past, were filed due to the dishonest atmosphere of fear and intimidation created by the
tax collector and the local assessors' offices; not because there is any law requiring me to do so. Once I
discovered the tax agencies are lying to the public, I have felt it is my responsible duty to society to
terminate my voluntary participation. Because such returns were filed under Threat, Duress, and
Coercion (TDC), and no two-way contract was ever signed with full disclosure, there is nothing in any
past filing of returns that created any valid contract. Therefore, no legal obligation on my part was ever
created. 6. The use of a driver's license. As a free Sovereign, there is no legal requirement for me to
have such a license, for traveling in my car, as technically, the unrevealed legal purpose of driver's
licenses is commercial in nature. Since I don't carry passengers or freight for hire, there is no law
requiring me to have a license to travel for my own pleasure and that of my family and friends.
However, because of the lack of education of police officers on this matter, should I be stopped for any
reason and found to be without a license, it is likely I would be harassed. Therefore under duress, I
carry a "license" to avoid extreme inconvenience. 7. State plates on my car. Similarly, even though
technically, my car does not fit the legal definition of a "motor vehicle", which is used for commercial
purposes, nevertheless, I have registered it with the state and carry the state plates on it, because to
have any other plates or no plates at all, causes me the risk of police officer harassment and extreme
inconvenience. 8. Declaration of citizenship. Any document I may have ever signed, in which I
answered "yes" to the question, "Are you a united states citizen?" -- cannot be used to compromise my
status as a Sovereign, nor obligate me to perform in any manner. This is because without full written
disclosure of the definition and consequences of such supposed "citizenship," provided in a document
bearing my signature given freely without misrepresentation or coercion, there can be no legally
binding contract. I make no allegiance to any earthly government, I am neutral to all. 9. Past voter
registration. Similarly, since no obligation to perform in any manner was ever revealed in print, as part
of the requirements for the supposed "privilege" to vote for government officials, any such previous
registration on my part cannot be legal evidence of any obligation to perform. Likewise, I have granted
NO jurisdiction over me, to any political office. It is my inherent right to vote on elections or issues
that I feel affect all of society; NOT because I need anyone to rule over me. On the contrary -- I have
used the voting process only to instruct my public servants what a Citizen and Sovereign would like
done. 10.Marriage license. The acquisition of a marriage license is now being revealed as being
necessary only for slaves. The act of a Sovereign such as myself obtaining such a license, through
social custom and ignorance of law, has no legal effect in changing my status. This is because any such
change in status, if any may be supposed to occur, could happen only through a hidden and unrevealed
contract or statute. Since no hidden, unrevealed, and undisclosed information, if it exists, can be
lawfully held to binding, it is null and void. 11. Children in public school. The attendance of my
children in government-supported "public" schools or government-controlled "private" schools does
not create any legal tax obligation for me, or any other legal obligation, because I never signed a
contract agreeing to such obligation for the supposed "privilege" of public school attendance. If any of
my children have attended government supported "public" or controlled "private" schools, such was
done under duress and not out of free will. Be it known that I regard "compulsory state education" as a
violation of the natural and universal common law of freedom of choice. 12. Use of semantics. There
are some immature people with mental imbalances, such as the craving to dominate over other people,
who masquerade as "government." Just because they alter definitions of words in the law books to their
supposed advantage, doesn't mean we have to accept those definitions. The fact that they define the
words "person," "address," "mail," "resident," "motor vehicle," "driving," "passenger," "employee,"
"income," and many others, in ways different from the common usage, so as to be associated with a
subject or slave status, means nothing in real life. Because the courts have become entangled in the
game of semantics, be it known to all courts and all parties, that if I ever signed any document or spoke
any words on record, using words defined by twists in the law books different from the common usage,
there can be no effect whatsoever on my Sovereign status in society thereby, nor can there be created
any obligation to perform in any manner, by the mere use of such words. Where the meaning in the
common dictionary differs from the meaning in the law dictionary, it is the meaning in the common
dictionary that prevails, because it is more trustworthy. *Such compelled and supposed "benefits"*
include, but are not limited to, the aforementioned typical examples. My use of such alleged
"benefits"* is under duress only, and is with full reservation of all my common law rights. I have
waived none of my intrinsic rights and freedoms by my use thereof. Furthermore, my use of such
compelled "benefits" may be temporary, until better alternatives become available, practical, and
widely recognized.

 I declare my self to be in contract with myself… by the following.. so this file stands as my own
UCC1 filing.
Any contract in consideration to my real person is now considered null and void, unless that any
person comes forward now to claim it or myself within 15 days of reception.

Let it be know that I never signed my social security card that was obtained for myself without my
knowledge prior to being an adult. I am merely the authorized agent for this property and so I take part
in no liability or responsibilities ucc 1-308.

I claim my offspring listed here and do so declare ownership over their bodies no vaccine, no to
granted authorization to Dept Family Services, Child Support Etc no to any gov / fed or private use,
rent etc.

Children Under my Jurisdiction 1st Position Claim & Lien Notice – Birth Certificate & Social Security
Numbers
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Total Lien Amount $_______________________________________________
I declare all of this information to be truth as guardian(s) our family seal / name:
___________________________________________________________________________________
I am not property and not owned my any party but am a self governed being with complete jurisdiction
of my body and I do not consent to any of the following:

 I do not know what is in your vaccine.

 I do not believe your vaccine is safe.
 I know that many vaccines have been found to contain toxic adjuvants and toxic foreign
materials.
 I know that toxic contamination is present in vaccines which are easily preventable with current
technology. This suggests intentional contamination of vaccines with toxic agents.
 I know that many vaccines are not effective and actually cause the ailment they are purported to
mitigate.
 I know that adjutants are put into vaccines to “shock” the immune system into extreme
response, and that causes biological “crisis”, stress and damage to the immune system, the
blood and the whole body.
 I know that vaccine death and injury statistics and information are suppressed by media which
receives billions of dollars in pharma advertising annually.
 I know that vaccine death and injury statistics and information are suppressed by government in
which pharmaceutical regulatory agencies are largely run and controlled by pharma industry
executives, loyalists and lobbyists.
 I know that vaccines kill hundreds of thousands of people per year.
 I am aware of reports that vaccine experiments have caused tens of thousands of cases of polio
and other diseases and injuries in India, Asia, Africa, The Philippines and many other locations.
 I know that vaccines are so hazardous that the vaccine industry lobbied for, and received
immunity from the harm vaccines are causing.
 I know that taxpayers have paid billions of dollars to families who’s members were injured or
killed by vaccines.
 I do not trust the vaccine industry, government agencies or international agencies which seem to
be acting on behalf of vaccine sales and promotion and suppressing information of vaccine
hazards.
 I know that most vaccines have not been tested or proven safe.
 I know that under current law all physicians and healthcare workers must have my consent to
administer medicine to me. My consent is hereby denied and refused.
 I know that if someone is not a doctor, such as an elected official or bureaucrat, they may not
administer medicine at all, much less “mandate” medical treatments for the general population.
 I know it is possible to mitigate and control all contagious diseases with safer and more
effective means than vaccination.
 Anyone who claims privilege to inject materials in my body without my consent is my enemy
and is criminal.
 I will treat anyone who threatens to violate my body as a criminal assailant.
  No, you may not vaccinate me or my children. If you try, I will exercise my right to self defense
against you and your accomplices to any extent I deem necessary to protect ourselves.
 Forced vaccination is not authorized or permitted under Law. If there is a code or statutory
“mandate” for forced medication, it is unconstitutional, unlawful and unenforceable.
 You may not attempt or threaten non-consensual vaccination, and if you do, you will be dealt
with in a manner to restore rule of law, justice and to protect our right to personal physical
security.
 Your ignorance of vaccine hazards and medical rights and your inability to understand the facts
above do not give you any immunity or any license to commit the crime of forced non-
consensual medication.
 Can you name every ingredient of your vaccine? Presumably not.
 Can you predict the physical effects of each of those ingredients? No.
 Can you predict the consequences of combining those ingredients? No.
 Have you offered to personally take full responsibility to pay for any harm your vaccine causes?
No.
 Therefore you do not have the slightest authority or privilege to forcibly administer vaccines.
 Can you prove in court a contract of compelled performance?
 The piercing or puncturing of my / our family skin to cause blood is an attack. And so is a
violation of personal rights.
 The puncturing of skin via a needle maybe contaminated and cause injury to which you / this
institution will be held directly and personally liable financially & legally. No Exemptions.
 The use of such agents including alcohol or iodine has been know to cause reactions! And so if
any part of the process contains these elements we will be opting out to the full extent.

We are distancing ourselves from any for of control, ownership, color of law, any alleged, unknown
attachments associated with our family listed here due to having a social, birth certificate or etc. is only
attached to the legal fiction. The ALL CAPS commercial business with or bearing the name exact in
appearance to the names mentioned but ours as real beings are in lower caps. One being a flesh and
blood living being which was born free with in alienable rights the other a Commercial business. The
latter we are only authorized agents with no liability or responsibility if anything is requested, asked, to
be used, taken, injected, etc will only pertain to the commercial entity. The real being(s) were created
and by birth right of this state claim out jurisdiction of a State Citizen / US national / Non Resident
Alien and or Living Free Being of God.
Let it be known I am apart of a private jurisdiction(s)! There is the Federal Citizen 14t Amendment
Citizenship by use of minor benefits limited to my / our occasional use of social security card, birth
certificate etc. However this jurisdiction is limited to the Commercial Entity and not my / our physical
bodies for any reasons! We are nationals of USA Republic and being born in the republic jurisdictional
state of______________. Not to be confused with the CORPORATE version or STATE OF – your
states all cap NAME here! And most important I am a celestial soul existing for an unknown time
period in this Earth made vessel by God that I claim full ownership...with full authority and power
rights of a divinity. With no superior ownership nor jurisdiction other the Almighty.
Our Faith, Religion & Inherit Right of Life
By the power invested in us as creation of God we have the right to invoke our freedoms. In this we do
not believe in the use of man made chemicals, technology, serums, gene alterations, etc to be utilized
into our bodies. As these products have been proven to cause side effects & deaths to which you can
not guaranty 100% safety for my family. Our faith prevents this and in speaking with our health
advisors it has been determined that if a shot, injection or vaccine contains any of the following it could
be extremely hazardous to our family health common adverse reactions from Thermosil. Mercury,
aborted baby tissue, sucralose, aluminum, fragrance, detergents and stabilizers! Here are additional
substances that are also on the hazardous “Do Not Inject” list for our family members:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
It is against the constitution of the USA Republic as us Nationals to attempt compelled performance,
compelled financial responsibility and remove the ability to file lawsuit against these actions while also
protecting the manufactures.
Above here is where you list any thing you really are allergic to or you THINK aka ingredients
contained in the shots.. I’d google what are the ingredients in shots! Delete yellow.
GPS Tracking Chips and Technology
This is also a formal notification that my family nor myself are under any agreement, contract or
mandate to comply with any form benefit that requires compelled performance. This is to include any
software, technology, DNA manipulation, virus, modified virus or anything unnatural to be used in, on,
within our private vessels to determine our location. Nor to be used to modify our bodies, sit dormant,
control our actions or provide and form or surveillance know or unknown. If any violations of this
occur any party involved agrees to be held liable personally, financially and to be prosecuted. Fine for
each occurrence $10M Dollars U.S. The continual fee for the violation will be $50K a month payable
on the first 1st of each month till resolved or canceled my the proper authority.
Voiding any Certificate / Paper Ownership Claim.
If me or my child is required or near to force-ably against will required to take part in this act the
department fed etc must provide remedy per this request. Or pay $$250,000.00 U.S. per person per
incident as a service fee.
Let it be known that before such actions we would formally request the contract that binds us to such
actions bearing a signature from each party. Disclose the exact section that pertains to vaccines,
technology etc in this agreement that existed at the time of signing. It will be known that if in fact this
exists I was never aware that it could be updated or a living contract. Hence I did not knowingly accept
nor do I accept at this time.
I have read the Vaccine Information Statement(s) from the Centers for Disease Control and Prevention,
which explain the vaccine(s) and the disease(s) they prevent. I have had the opportunity to discuss
these with my healthcare provider, who has answered all of my questions regarding the recommended
vaccine(s). I understand the following:  The purpose of and the need for the recommended vaccine(s)
 The risks and benefits of the recommended vaccine(s)  If (I) my child (do) does not receive the
vaccine(s), the consequences may include:  Contracting the illness the vaccine should prevent (The
outcomes of these illnesses may include but are not limited to one or more of the following:
hospitalization, pneumonia, brain damage, meningitis, seizures, deafness, and death.)  transmitting
the disease to others (If an outbreak of vaccine-preventable disease occurs at my child’s school or child
care and my child is not protected, he/she may not be permitted to return until risk of catching the
disease has passed.)  My healthcare provider, the Immunization Office, the American Academy of
Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and
Prevention all strongly recommend that these vaccines be given according to the published Advisory
Committee on Immunization Practices (ACIP) schedule. Nevertheless, I have decided at this time to
decline the vaccine(s) recommended for me / my child, as indicated above, by this Affidavit the
appropriate box under the column titled “declined.” I understand that failure to follow the
recommendations about vaccination may endanger the health or life of me or my child and others with
whom I or my child might come into contact. I understand that I may discuss this issue with my (my
child’s) healthcare provider and that I may change my mind and accept vaccination for myself (my
child) anytime in the future. I understand that my refusal to have my child vaccinated does not exempt
my child from school or child care facility immunization requirements and that he/she will be unable to
attend school or child care without the required vaccinations. Client/Parent/Guardian.
Vaccines are in direct violation of the Nuremburg Code. Forced, coerced, and mandated vaccinations
are in fact violations of these principals. A violation of Article 6 of the Unesco 2005 statement on
Bioethics and Human Rights. Article 6 Section 1, Article 6 Section3. Lack of consent, harm, potential
death, health impact events, gene modifications, potential loss of income, and potential reduced quality
of life etc.
Mandate
The Government & this Institution are promoting these measures under a “Mandate” which is not law.
Now lets look at the legal definition of a mandate by blacks law legal dictionary. As follows: 1.An
order from an appellate court to an inferior court. 2. A judicial command given to an officer to carry
out. 3. An electorates overwhelming show of approval to another candidate. 4. Roman & Civil Law – A
written command given by a principal to an agent, a commission or contract by which one person has
authority over another to transact one or more affairs for the principal (which doesn’t imply nor consent
to self infliction).The mandatary is bound to use reasonable care in performance, while the mandator is
bound to indemnity against loss in performing service. The contract a mandate tcan be done either
gratuitous or onerous ( by ones own will and or without hardship ).
This being the case please explain to me how I am a agent, court, officer, under contract to self inflict
or etc. A contract is an agreement which wasn't in place at the time of my hiring, nor can I be forced to
place myself in danger for any position. As I am not property forced events are slavery and illegal in
the USA.

Exemptions
This institution is Government controlled or under Federal jurisdiction this being the case there are
recognized exemptions to be followed if requested. Thereby I a formally requesting the following
exemptions to be placed on recorded and to be respected. HR is to take due notice, implement, file and
etc. the materials here officially & for memorial. If any one here is not familiar with the exemptions
you are hereby to do your research before any violations that may occur in the violation of my rights.
Also should it be absolutely imperative or job dependent that I must perform an action that violates this
but places my job / position with the company in peril. Feel free to contact myself to discuss options
but only after all of the listed exemptions have been verified by the mandate to not recognized or
effective. Thank you for your time.
My Exemptions are listed here are as follows:
1. Health Exemptions – My genetic DNA material may have unknown results.
2. Political Exemptions – I am not party to the State or U.S. Corp.
3. Personal Exemptions – I do not agree with being forced and fear for my beings safety.
4. Religious Exemptions – My private faith is protected by the Constitution of the USA.
5. US National / Foreign National “Status Exemptions” – Immunity.
6. International Treaty Exemptions – Nuremberg Code.
7. Death Exemptions – If there is even1% of “Death” as a result its not legal.
8. No Contract to Compelled Performance Exemptions – It is illegal to compel someone to
perform an action without their consent and its illegal to to threat, force or coheres.
9. Privacy Laws Exemption – This is a private matter and no institution can force me to reveal or
take part in anything that reveals my privacy.
10. Discrimination – Preventing my person from activities / employment etc based on health,
vaccination, immune system, lack of vaccination, mask etc goes against the law / unlawful.
11. Genetic / DNA Exemption – My right is to not have my personal property DNA / body
modified with out $2M fee. Company or state provided $2M insurance coverage in case
damage, death of health impact events (loss of quality of life), and by my right to refuse UCC 1-
308.
12. Natural Immunity Exemption – I am declaring that I have either had the virus., disease or
sickness and so by my immune system considered to be protected / fully immune.
 13. Hipaa Laws & Rights - The Health Insurance Portability and Accountability Act of 1996
(HIPAA) is a federal law that required the creation of national standards to protect sensitive
patient health information from being disclosed without the patient's consent or knowledge.
14. Philosophical Exemption – This goes against my devotion toward the study of the fundamental
nature of knowledge, life's pure experience(s), reality, and existence.
15. Medical Exemption: I formally request to opt out of any and all vaccines from this point
forward due to medical exemption. My medical conditions are confidential and private.
16. The alleged vaccine shots/jabs that are available are overwhelmingly Emergency Use
Authorization (EUA) only, to which federal law requires the right of refusal, under Title 21
U.S.C. § 360bbb-3(e)(1)(A)(ii)(III) of the Federal Food, Drug, and Cosmetic Act.
17. Anti-Body Exemption: I formally request to be tested for antibodies which are naturally
occurring remedies / protection from Covid-19 etc. The same results are obtained from an
injection / vaccination and so thus I may be already immune.
18. Mask Exemption: If the final result of this matter must be such then I will comply with initial
standards of cleanliness, distancing and wearing a basic mask. These method were provided by
the Federal Government as approved and so this remedy is acceptable to continue working
without being a health threat as a last resort.
19. Mandate Exemption: Has this Mask / Vaccination Mandate actually been written into and voted
into positive law? If not it is merely a strong encouragement and or a highly advisable
suggestion. It is is law please provide proof of this event and when it was past along with how it
direction applies to a person of my status.
20. 1st Amendment: Constitutional protection claim violation of my “Right to Religious Beliefs &
Practices” may be pursued for penalties, damages and rico acts etc.
21. 9th Amendment: States that American Nationals have additional rights even if not listed here that
may be exercised with impunity. I therefore exercise my right to say “No” and failure to abide
by this, or fire (terminate my employment) is a violation of the Constitution. Which thereby
allows for this corporation to be liable for a lawsuit in Federal Supreme Court. To include the
max. fee’s, penalties, and all court costs to be included.
22. 10th Amendment: Federal Gov only has those delegated powers mentioned in the Constitution
and if not so specifically mentioned belongs to the People or State. And so there is none stating
a mandatory waive of health rights etc.

My Proper Nationality Status

8 USC 1101 (22) (b)
The term “national of the United States” means (A) a citizen of the United States, or (B) a person who,
though not a citizen of the United States, owes permanent allegiance to the United States of Amercia.

Foreign Sovereign Immunity Act

Under this Act I am not subject to any State or Federal jurisdictions. I am not subject to any forced
mandates, injections, forced acts etc. You are directed to due notice and file this information.
- Foreign Sovereign Immunity Act 28 USC § 1603, 1604, 1605, 1606, 1607, 1608, 1609, 1610, 1611

- 28 U.S. Code § 1604 Immunity of a Foreign State from Jurisdiction

18 U.S. Code § 878 - Threats and extortion against foreign officials, official guests, or
internationally protected persons:
(a) Whoever knowingly and willfully threatens to violate section 112, 1116, or 1201 shall be fined
under this title or imprisoned not more than five years, or both, except that imprisonment for a
threatened assault shall not exceed three years.
(b) Whoever in connection with any violation of subsection (a) or actual violation of section 112, 1116,
or 1201 makes any extortionate demand shall be fined under this title or imprisoned not more than
twenty years, or both.
(c) For the purpose of this section “foreign official”, “internationally protected person”, “national of
the United States”, and “official guest” shall have the same meanings as those provided in section
1116(a) of this title.
(d) If the victim of an offense under subsection (a) is an internationally protected person outside the
United States, the United States may exercise jurisdiction over the offense if (1) the victim is a
representative, officer, employee, or agent of the United States, (2) an offender is a national of the
United States, or (3) an offender is afterwards found in the United States. As used in this subsection,
the United States includes all areas under the jurisdiction of the United States including any of the
places within the provisions of sections 5 and 7 of this title and section 46501(2) of title 49.
(Added Pub. L. 94–467, § 8, Oct. 8, 1976, 90 Stat. 2000; amended Pub. L. 95–163, § 17(b)(1), Nov.
9, 1977, 91 Stat. 1286; Pub. L. 95–504, § 2(b), Oct. 24, 1978, 92 Stat. 1705; Pub. L. 103–272, § 5(e)
(2), July 5, 1994, 108 Stat. 1373; Pub. L. 103–322, title XXXIII, § 330016(1)(K), (N), Sept. 13,
1994, 108 Stat. 2147, 2148; Pub. L. 104–132, title VII, §§ 705(a)(4), 721(e), Apr. 24, 1996, 110 Stat.
1295, 1299.)

I will continue to operate in my current tax status / obligation as same until it is changed in the future.
By law if my rights are violated a lawsuit for damages, death, paid suffering, loss of quality of life,
termination, loss of income may result. Implying that this institution would be at that point then act as
party held liable. Fees will be accessed on a per item mentioned basis at the time of incident but not
less then $50K incursion fee plus applicable damages including court costs. This applies from this date
forward with no expiry or modifications etc unless I do so by signed agreement.
Fee Schedule for Violations
1. 250K U.S. for every initial violation committed without prior oral / written consent.
2. 25K U.S. each month initial fee is not paid until resolved or paid in full.
3. Full financial responsibility for health costs (ongoing medical), all legal fees and associated costs etc.
4. Death fee of 5M U.S. and or a health impact event (unable to live a normal life standard) fee of 4K
U.S. monthly till resolved.

No expiration to my claim. Rights transferred to next of appointed member, family or next of kin.

THIS SECTION IS OPTIONAL if your local notary wont do this then delete and use the lower
section. Use one section only the jurat or the self signature and sign.

JURAT
A notary public or other officer completing this Affidavit verifies only the identity of the individual who signed the
document to which this section is attached, and not the truthfulness, accuracy, or validity of this document.

State of Wisconsin )
) For Verification Purposes Only
______________ County )

On _____________________________ before me,

________________________________________________________________________________
Date Here Insert Name and Title of Notary

By Special Appearance, in Propria Persona, proceeding Sui Juris personally appeared ______your
name_______, has declared to be a national of the United States of America Republic (22) The term
“national of the United States” means (A) a citizen of the United States, or (B) a person who, though
not a citizen of the United States, owes permanent allegiance to the United States of America Republic.
8 USC § 1101(b)(22). By means of U.S. certificate of live birth, Authenticated Birth Certificate,
Pictured ID / License (no jurisdiction implied), Family Bible, Sworn Elder Family or USA Passport.
Who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his /her / their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s) or the entity upon behalf of which the person(s) acted, executed the instrument. Age of the
Majority.

I certify under PENALTY OF PERJURY under the

laws of the State of Wisconsin that the foregoing
paragraph is true and correct.

WITNESS my hand and official seal.

Common Law Seal of Natural Being

________________________________/____/___
Place Notary Seal
 ALTERNATIVE SIGNATURE SECTION TO BE REMOVED USE ONLY ONE. Make copies.. us e
this section only if the notary wont use the above one.. And no you dont have to get it notarized. Your
choice.. notary helps but is not mandatory.

– A Living Soul & Free Being

ALL RIGHTS RESERVED UCC 1-308
Foreign National Jurisdiction without the UNITED SATES
Constitutional USA Republic Citizen – Common Law Claimant
Without Prejudice / NON-ASSUMPSIT / NON-PERSON / NON-DOMICILED /NON-
RESIDENT / NON COMMERCIAL ENTITY / NON-COMBATANT / NON-TAXPAYER