JANE HENRIETTA DOE ESTATE

Office of the Executor/ Executrix/ Administrator

123 Any Address
Any City, State, Zip
Certified Mail No.____________________________

To: Name, Title Re: State of Emergency for COVID19

Address
City, State Zip

Dear ________________ (President, US Attorney, Governor, Public Health Officer, Sheriff, Mayor, etc.)

Your declaration of a State of Emergency for the COVID-19 diagnosis criteria for a series of pneumonia
and influenza related symptoms and the allegations of the existence of a “novel coronavirus” is based on a
series of assumptions that are patently false.
According to the International Committee on Taxonomy of Viruses’ (ICTV) Coronaviridae Study Group
(CSG) publication on March 2, 2020, the preliminary data suggesting that there was sufficient variation to
determine this to be a novel virus vs. a mutation of known coronaviruses, was not based on established
scientific principles but was responsive to the World Health Organization’s prior unfounded declaration
of novelty of both the virus and a new disease;
There could be no independent verification of the epidemiologic models predicting dire infection and
mortality rates as the underlying models and data were not published, and when sought, were reportedly
corrupted so as to make their examination impossible;
In violation of State law, no medical or scientific evidence was provided to establish even causal links
between the SARS CoV-2 and the symptoms of COVID-19, relying instead on foreign government
hearsay and conjecture;
Since 2003, the U.S. Department of Health and Human Services and their subordinate organizations – the
National Institute of Allergy and Infectious Diseases (NIAID) and the Centers for Disease Control and
Prevention (CDC) – maintained a patent preventing any independent organization from testing for the
presence of coronavirus transmissible to humans through 2018 resulting in a complete lack of testing
technologies;
No State official reviewed for accuracy or veracity any of the causal statements made in the Declaration
of Emergency which contain false, misleading, and terror inducing statements;
In violation of well-established legal precedent from Jew Ho v. Williamson, 103 F. 10, 26 (C.C.N.D. Cal.
1900) and subsequent public health law, arbitrary and capricious rules were inflicted upon a part of the
population that were not applied generally, resulting in the unlawful confinement of a healthy population
with no basis in science or fact;
The Governor failed to provide adequate testing to confirm or deny the presence or absence of “a novel
coronavirus” and, based on recent reports from testing of incarcerated persons reported by Reuters, 96%
of prisoners testing positive for coronavirus are asymptomatic, demonstrating a failure to establish even a
statistical link between the virus and the disease;
Neither the Governor nor any public health officer has followed evidence-based, peer-reviewed, clinical
science showing that neither social distancing (of up to 6 feet of separation), nor the wearing of masks has
any clinical effect in a healthy population and that instituting such policies is exclusively for the
inducement of fear and terror in the population;
As result of these and other established facts, your orders and those that follow from these orders issued
in violation of the State Constitution, are illegal and unenforceable. I hereby demand that you
immediately cease and desist in your suspension of my Constitutional rights and those of the common
citizenry.
Sincerely,
_________________________

For your reference, please review the following facts:

Assertion:
On April 25, 2003, the United States Department of Health and Human Services Centers for Disease
Control and Prevention (hereinafter, “CDC”) filed an application for a United States (Application
Number Coronavirus isolated from humans”. Claim 3 – US46592703P, subsequently issued as U.S.
Patent 7,776,521) entitled “A method of detecting a severe acute respiratory syndrome-associated
coronavirus (SARS-CoV) in a sample…; and, Claim 4 – A kit for detecting a severe acute respiratory
syndrome-associated coronavirus (SARS-CoV) in a sample…, provided the CDC with a statutory market
exclusion right for the detection of and sampling for severe acute respiratory syndrome-associated
coronavirus (SARS-CoV). Securing this right afforded the CDC exclusive right to research, commercially
exploit, or block others from conducting activities involving SARS-CoV since 2003. On September 24,
2018, the CDC failed to pay the required maintenance fees on this patent and their rights expired with no
notification issued by CDC alerting the private sector to this decision.
From April 2003 until September 2018, the CDC owned SARS-CoV, its ability to be detected and the
ability to manufacture kits for its assessment. During this 15-year period, the effect of the grant of this
right — ruled unconstitutional in 2013 by the United States Supreme Court in the case of Association for
Molecular Pathology et al. v. Myriad Genetics – meant that the commercial exploitation of any research
or commercial activity in the United States involving SARS-CoV would constitute an infringement of the
CDC’s illegal patent.
It appears that, during the period of patent enforcement and after the Supreme Court ruling confirming
that patents on genetic material were illegal, the CDC and National Institute of Allergy and Infectious
Diseases led by Anthony Fauci (hereinafter “NIAID” and “Dr Fauci”, respectively) entered into trade
among States (including, but not limited to working with Ecohealth Alliance Inc.) and with foreign
nations national entities (specifically, the Wuhan Institute of Virology and the Chinese Academy of
Sciences) through the 2014 et seq National Institutes of Health Grant R01AI110964, to exploit their
patent rights.
It further appears that, during the period of patent enforcement and after the Supreme Court ruling
confirming that patents on genetic material was illegal, the CDC and National Institute of Allergy and
Infectious Diseases (hereinafter “NIAID”) entered into trade among States (including, but not limited to
working with University of North Carolina, Chapel Hill) and with foreign nations (specifically, the
Wuhan Institute of Virology and the Chinese Academy of Sciences represented by Zheng-Li Shi) through
U19AI109761 (Ralph S. Baric), U19AI107810 (Ralph S. Baric), and National Natural Science
Foundation of China Award 81290341 (Zheng-Li Shi) et al. 2015-2016.
It further appears that, during the period of patent enforcement and after the Supreme Court ruling
confirming that patents on generic material was illegal, the CDC and NIAID entered into trade among
States (including, but not limited to working with University of North Carolina, Chapel Hill) and with
foreign nations to conduct chimeric construction of novel coronavirus material with specific virulence
properties prior to, during, and following the determination made by the National Institutes for Health in
October 17, 2014 that this work was not sufficiently understood for its biosecurity and safety standards.
In this inquiry, it is presumed that the CDC and its associates were: a) fully aware of the work being
performed using their patented technology; b) entered into explicit or implicit agreements including
licensing, or other consideration; and, c) willfully engaged one or more foreign interests to carry forward
the exploitation of their proprietary technology when the U.S. Supreme Court confirmed that such patents
were illegal and when the National Institutes of Health issued a moratorium on such research.
Reportedly, in January 2018, the U.S. Embassy in China sent investigators to Wuhan Institute of Virology
and found that, “During interactions with scientists at the WIV laboratory, they noted the new lab has a
serious shortage of appropriately trained technicians and investigators needed to safely operate this high-
containment laboratory.” The Washington Post reported that this information was contained in a cable
dated 19 January 2018. Over a year later, in June 2019, the CDC conducted an inspection of Fort
Detrick’s U.S. Army Medical Research Institute of Infectious Diseases (hereinafter “USAMRIID”) and
ordered it closed after alleging that their inspection found biosafety hazards. A report in the journal
Nature in 2003 (423(6936): 103) reported cooperation between CDC and USAMRIID on coronavirus
research was followed by considerable subsequent collaboration. The CDC, for what appear to be the
same type of concern identified in Wuhan, elected to continue work with the Chinese government while
closing the U.S. Army facility.
The CDC reported the first case of SARS-CoV like illness in the United States in January 2020 with the
CDC’s Epidemic Intelligence Service reporting 650 clinical cases and 210 tests. Given that the suspected
pathogen was first implicated in official reports on December 31, 2019, one can only conclude that CDC:
a) had the mechanism and wherewithal to conduct tests to confirm the existence of a “novel coronavirus”;
or, b) did not have said mechanism and falsely reported the information in January. It tests credulity to
suggest that the WHO or the CDC could manufacture and distribute tests for a “novel” pathogen when
their own subsequent record on development and deployment of tests has been shown to be without
reliability.
Around March 12, 2020, in an effort to enrich their own economic interests by way of securing additional
funding from both Federal and Foundation actors, the CDC and NIAID’s Dr Fauci elected to suspend
testing and classify COVID-19 by capricious symptom presentation alone. Not surprisingly, this was
necessitated by the apparent fall in cases that constituted Dr. Fauci’s and others’ criteria for depriving
citizens of their 1st Amendment rights. At present, the standard according to State and Territorial
Epidemiologists Interim-20-ID-01 for COVID-19 classification is:
In outpatient or tele-health settings at least two of the following symptoms must be indicated: fever
(measured or subjective), chills, rigors, myalgia, headache, sore throat, new olfactory and taste disorder(s)
OR
at least one of the following symptoms must be indicated: cough, shortness of breath, or difficulty
breathing OR Severe respiratory illness with at least one of the following:
Clinical or radiographic evidence of pneumonia, or
Acute respiratory distress syndrome (ARDS).
AND No alternative more likely diagnosis
Laboratory Criteria for Reporting
Detection of SARS-CoV-2 RNA in a clinical specimen using a molecular amplification detection test.
Detection of specific antigen in a clinical specimen.
Detection of specific antibody in serum, plasma, or whole blood indicative of a new or recent infection
serologic methods for diagnosis are currently being defined
After inflicting grave harm to the people of the United States of America through economic hardships
resulting from their allegations of an “epidemic” or “pandemic”, the CDC and the NIAID set forth, and
the President of the United States and various Governors in the respective States promulgated, standards
for lifting restrictive conditions which are in violation of the 1st Amendment to the Constitution and
serve exclusively to enrich themselves. Both the presence of a vaccine or treatment and, or, the
development of testing — each of which solely benefit the possible conspiring parties and their co-
conspirators — are set forth as a condition for re-opening the country. This appears to be an unambiguous
violation of the Sherman Act and, if so, should be prosecuted immediately to the full extent of the law.
The CDC and WHO elected to commit to a narrative of a novel coronavirus – exhibiting properties that
were anticipated in the U.S. Patent 7,618,802 issued to the University of North Carolina Chapel Hill’s
Ralph Baric – and, in the absence of testing protocols, elected to insist that SARS-CoV-2 was the
pathogen responsible for conditions that were consistent with moderate to severe acute respiratory
syndrome.
U.S. Constitution:
Article One, Section 8, clause 8,
To promote the progress of science and useful arts, by securing for limited times to authors and inventors
the exclusive right to their respective writings and discoveries
By Renewing their Illegal Patents on February 17, 2014 the CDC violated Article 1, Section 8, Clause 8
of the U.S. Constitution
By Renewing their Illegal Patents on February 17, 2014 the CDC willfully violated the law using tax-
payer funds in light of the Supreme Court ruling on June 13, 2013
Article One, Section 9, clause 2,
Which states that “The privilege of the writ of habeas corpus (a recourse in law challenging the reasons or
conditions of a person’s confinement) shall not be suspended, unless when in cases of rebellion or
invasion the public safety may require it.”
THERE IS NO CLINICAL DATA SHOWING THAT THE “RESTRAINT OF HEALTHY
INDIVIDUALS” HAS ANY EMPRICAL DATA SUPPORTING ITS USE. NO EVIDENCE
SUPPORTING EMERGENCY DECLARATIONS HAVE BEEN OFFERED WITH THE EXCEPTION
OF STATEMENTS MADE BY COLLUDING PARTIES SEEKING TO BENEFIT FROM
VACCINATIONS, TESTING OR THE COMBINATION – NEITHER OF WHICH CAN BE
REASONABLY EXPECTED GIVEN THE PATENTS GRANTED TO AND HELD BY THE
COLLUDING PARTIES.
The Sherman Act and Clayton Act violations consist of receiving and directing funding only to those
parties colluding around the infringement of the CDC’s illegal patent.
CDC; NIAID; University of North Carolina, Chapel Hill; Wuhan Institute of Virology; National Institutes
of Health; U.S. Department of Health and Human Services; President’s Task Force; Governors except
North Dakota, Nebraska, Arkansas, Utah, Wyoming, South Dakota, and Oklahoma
Possible violation of 15 U.S. Code § 19
Dr. Fauci is on the Leadership Council of the Bill and Malinda Gates
Global Vaccine Action Plan
DOMESTIC TERRORISM – Still in Effect Until March 15, 2020
Section 802 of the USA PATRIOT Act (Pub. L. No. 107-52) expanded the definition of terrorism to
cover “”domestic,”” as opposed to international, terrorism. A person engages in domestic terrorism if they
do an act “dangerous to human life” that is a violation of the criminal laws of a state or the United States,
if the act appears to be intended to: (i) intimidate or coerce a civilian population; (ii) influence the policy
of a government by intimidation or coercion;
Lastly, current policing, fining, arrests and harassment throughout the country and in my County in this
case, is in violation of not only First Amendment “abridging the right of people to peaceably assemble”
but more narrowly:
Title 18 U.S.C., Section 242 Deprivation of Rights Under Color of Law:
Whoever, under color of any law, statute, ordinance, regulation, or custom, willfully subjects any person
in any State, Territory, Commonwealth, Possession, or District to the deprivation of any rights, privileges,
or immunities secured or protected by the Constitution or laws of the United States, or to different
punishments, pains, or penalties, on account of such person being an alien, or by reason of his color, or
race, than are prescribed for the punishment of citizens, shall be fined under this title or imprisoned not
more than one year, or both; and if bodily injury results from the acts committed in violation of this
section or if such acts include the use, attempted use, or threatened use of a dangerous weapon,
explosives, or fire, shall be fined under this title or imprisoned not more than ten years, or both; and if
death results from the acts committed in violation of this section or if such acts include kidnapping or an
attempt to kidnap, aggravated sexual abuse, or an attempt to commit aggravated sexual abuse, or an
attempt to kill, shall be fined under this title, or imprisoned for any term of years or for life, or both, or
may be sentenced to death.
As a concerned Patriot, proud American and Private citizen of this country/county, I willfully and
lawfully Notice you on the above statements for your immediate attention. It is my assertion that the
above facts must be considered for the immediate removal and suspension of any and all continued
unlawful, unconstitutional and draconian measures adversely affecting citizens. Henceforth any measures
related to and known as ‘shelter in place,’ quarantine, ‘non-essential’ work, social distance, and the
closure of public spaces will be considered unconstitutional and nothing more than an unlawful attempt at
‘social engineering.’ Finally, I request your support and immediate investigation of any ‘sworn’
Governmental official at local, State or Federal levels for their willfully complicit or knowingly criminal
misconduct of their Constitutional duties in the service of their office.
In closing, I welcome your correspondence and am hopeful that you take this matter seriously on behalf
of my family and fellow Private citizens currently being impacted by the ‘illegal’ actions outlined above.
Lastly, I will be submitting this same letter to all related local, State and Federal Gov’t representatives
including the Attorney General and The Department of Justice Tort Claims Division for considered civil
and criminal legal action on behalf of myself and fellow Private citizens.
I declare under penalty of Perjury WITHOUT the United Stated that the above is the Truth, the Whole
Truth and nothing but the Truth to the best of my first hand knowledge and overstanding.

Sincerely yours,
_____________________
 JANE HENRIETTA DOE ESTATE
Office of the Executor/ Executrix/ Administrator
123 Any Address
Any City, State, Zip
Certified Mail No.____________________________

School Name: _________________________________ Date: ________________________

School Address: _______________________________
City, State Zip: ________________________________
School Contact Name & Title: ____________________

Dear School Principal and/or Official:

This letter is to serve notice that you are in violation of the Constitution, as well as 18 U.S. Code §1962
with regard to your assistance in the imposition of false vaccine mandates and in the blockage of students
from their constitutionally-guaranteed right to a public education if failing to comply with said false
unconstitutional "mandates." It is also a crime under the code of law of hazing to require a child to be
vaccinated in order to attend school according to 10 U.S. Code § 6964.
The Bill of Rights guarantees that government cannot infringe, nor continue to infringe upon the rights of
the American people and is designed to ensure that the power of the government and its branches are kept
in check. Its constitutional amendments specifically guarantee the rights of the people and set clear
limitations of governmental power that have been perverted, misinterpreted and obscured.
It forbids the federal government from violating any of the unalienable rights of the people and authority
and sovereign rights are determined by the people and all rights not delegated to the Federal or State
governments by the people remains with the people.
The U.S. Constitution, as the Law of the Land, established by the people, for the people, and of the
people, to define and enforce the laws common to the American inhabitants needed to form and maintain
a functional government, protects and upholds the fundamental rights of the American people. The
government as well as all those contracted by them are contractually bound by the terms therein to act in
accordance with the u.S. Constitution to protect and defend the laws within that work to this end. to read
this thoroughly, completely and with comprehension. This document is of very serious nature and is not
frivolous. There will be no presumptions or assumptions, no tacit or implied agreements, no waiver of
rights, no hearsay, no lawyering nor attornment from the bench. I am requiring only the Truth, Facts,
Honor and Fair Justice. Otto 542, 23 L. Ed. 588 (1875).
The individual guarantees by our Constitution and treaties cannot be compromised or ignored by our
government or by its courts. This document is being recorded to hold accountable the individuals and
entities operating as part of the government or as contracted foreign agents who have sworn under oath or
who were meant to swear under oath, as is required in Title 5, Section 3331 of the United States Code.
The founders required an oath for all federal and state officials to uphold, protect, and defend the rights
afforded the lawful residents of this land.
The UNITED STATES government, the state governments, all of their agencies, and subdivisions such as
the city, county, boroughs, townships and banks are registered as corporations. According to California
Commercial Code 9307, "The UNITED STATES is located in the District of Columbia." The laws they
pass only apply to the federal corporate venues identified by zip code or in the 100 sq. mile DISTRICT
OF COLUMBIA. UNITED STATES Government Corporation was created February 21, 1871 by the
Forty-First This is reflected in U.S. Code, Title 28 JUDICIARY AND JUDICIAL PROCEDURE,
(Chapter 176) Section 3002 (15) (a, b, & c); which states that:
(A) a Federal corporation; (B) an agency, department, commission, board, or other entity of the United
States; (C) an instrumentality of the United States.
Corpus Juris Secundum, the second body of law, states: "The United States Government is a foreign
corporation with respect to a State.”
All corporations are fictions or artificial persons created under the authority of the law.
An artificial person or legal entity created by or under the authority of the laws of a state or nation,
composed, in some rare instances, of a single person and his successors..."
We the People, the private sector as the lawful indigenous residents of America have never formally
given up our lawful constitutional guarantees. In 1871, the united States of America became The United
States of America Corporation without the disclosure of the facts and without a vote of the people and
without full disclosure of what that meant and implied we were all slaves and residents of Washington D.
C.
In addition to the false government by artificial persons or entities cited above, and these entities
operating as foreign agents, enforcing false mandates requiring vaccinations for children to attend school,
or to be administered without parental consent, are violations of people's fundamental human rights as
stated in the Nuremberg Code.
No emergency has just cause to suppress the u.S. Constitution. 16Am Jur 2d., Sec. 98: "While an
emergency cannot create power and no emergency justifies the violation of any of the provisions of the
United States Constitution or States Constitutions. Public emergency such as economic depression,
especially for liberal construction of constitutional powers and it has been declared that because of
national emergency, it is the policy of the courts of times of national peril, so liberally to construed the far
as may not be clearly inconsistent with the constitution." To state coercion or intimidation in our school is
a crime according to the code of law 42 U.S. Code § 3617.
No evidence can be provided to support the need for vaccines or the impact of using vaccines on the mass
population, due to the criminal negligence admitted to by the CDC, HHS, FDA, and the drug
manufacturers in failing to conduct the Congressional mandate in accordance with 42 U.S.C-300aa-27
research, nor have they provided reports to the two committees, Committee on Health, Education, Labor,
and Pensions of the Senate (HELP) and the Committee of Energy and Commerce of House of
Representatives.
These are alleged mandates required by the World Health Organization under the order of the United
Nations, and have no jurisdiction on American soil. Under no circumstances are parents or children to be
denied their unalienable rights for any reason, and certainly not at the hand of foreign agents on American
soil who are therefore contractually bound by the Constitution. Any violation of these laws by any
member employed by the Board of Education, Board of Health or those operating in any government or
private capacity will result in both civil and criminal action against each individual, and entity. A grand
jury has already been called to hold the United States of America, Inc. accountable and to make them
comply with the constitution.
The aforementioned violations are not to be taken lightly. Govern yourselves in accordance with your
Sworn Oath of Office.
Sincerely,
_______________________________
Jane-Henrietta: Doe
Executor/Executrix/Administrator
JANE HENRIETTA DOE TRUST/ESTATE
When Recorded Return to:
_______________________
_______________________
_______________________

JANE HENRIETTA DOE ESTATE

Office of the Executor/ Executrix/ Administrator
123 Any Address
Any City, State, Zip

CONDITIONAL ACCEPTANCE OF VACCINATION

AGREEMENT BETWEEN VACCINE PROVIDERS AND VACCINATED
Certified Mail No. _________________________________________

Definitions:

Herein the terms “administration” and “administrators” refers to all parties providing and/or
“mandating” vaccine services and products including Presidents, Secretary Generals,
Congressmen/women, Senators, Military Generals, Governors, Attorney Generals, Mayors,
Sheriff’s, Chief’s of Police, Federal, State and Local Public Servants, Agents of any of the
aforementioned entities, vaccine Manufacturers, Marketers, Lobbyists, Distributors, Hospitals,
Clinics, Physicians, Nurses, Government Agents and Agencies, Healthcare Providers, Elected
Officials, Enforcement Persons, Agencies and Programs, and all other parties bringing
“mandated” vaccines to application or to market in any way.

This is agreement between the parties identified herein who on one hand, will receive
vaccinations or be affected by the consequences of vaccination including the vaccinated party/s
their guardians, representatives and all persons of common interests and, on the other hand, the
administrators and providers of the vaccine/s in all the various capacities. Those parties shall be
identified at the end of this document.

Individual intended for Vaccination:

Circle one: Adult Minor

Parents' or Guardian's Names and/or Head of Household:

____________________________________

Children's names (all family members):____________________________________

_____________________________________________________________________

Address:____________________________________
Phone:____________________________________

Other contacts if available:____________________________________

Name of vaccine to be provided_______________________________________________

As administrator of this vaccine I hereby agree to and with the following representations,
stipulations, terms, declarations and positions:

1. I am aware and understand that vaccines are not a perfect or fully proven method of
disease control.

2. I am aware and understand that vaccines are not 100% effective.

3. I am aware that vaccines have not been tested enough to show that they are 100% safe
and effective.

4. I am aware and understand that vaccines can cause death or injury and disease which
seriously and negatively affects the lives of vaccinated individuals, their families and
their communities.

5. I am aware and understand that vaccines, when causing disease and injury, can cause
major costs to individuals, families and communities, which costs are solely the
responsibility and liability of the causing agents which are the administrators and
providers of a harming or ineffective vaccine.

6. I am aware and understand that vaccines cause risk which is the sole responsibility of the
administrators and providers of the vaccine.

7. I am aware and understand that no one may be forced, coerced or compelled to accept
medical treatment or foreign substances inserted into their bodies without full voluntary
consent under full disclosure and that administering a treatment, harmful or otherwise,
without consent of all affected parties is unlawful and unethical.

8. I am aware and understand that vaccinations do, on occasion, cause harm, injury and
disease including the disease they are intended to prevent.

9. I am aware and understand that there are particular dangers and hazards of combining
more than one vaccination in one or sequential administrations and some of those hazards
and dangers are not well understood and have not been fully researched, tested or proven
safe or effective.

10. I understand that individuals have different physiologies and that a vaccination which
may be harmless to one individual may be quite harmful to another individual.

11. I am aware and understand that, prior to administration of any vaccination, administrators
of vaccinations must and shall disclose to all interested parties all known and presumed
 risks, hazards, harm and failures of vaccinations and all contents of the proposed
vaccination/s including all trace chemicals, adjuvants, components and contaminants
whether or not administrators consider those elements to be of consequence so that the
recipients of vaccinations can make fully informed decisions with regard to accepting
vaccination.

12. I am aware and understand that administration of vaccinations without full disclosure and
full voluntary consent of all interested parties and imposing risk and hazard in that way
represents criminal violation, malpractice and major liability of the administrators of the
vaccination to the vaccinated party/s should any negative consequences arise.

13. I am aware and understand that any person who attempts to enforce a “mandate” in
forcing or coercing vaccination or any other medical treatment upon any unwilling or
uninformed party, whether or not that “mandate” is provided in law, codes or regulations,
is personally fully liable for any and all harm, loss, damage, negative consequences of the
vaccination upon the vaccinated party and all other interested parties. That liability
extends to all administrators of that “mandate”, all legislators who were involved in the
creation of that “mandate” and all companies and individuals who promoted that
“mandate” through lobbying or other political action and all parties who participate in the
enforcement of the “mandate”.

14. I understand that, as an administrator or provider of any “mandated” vaccination I am

assuming all liability, obligation and responsibility for any and all negative and/or
unintended consequences of the administration of the vaccine and that I must “make
whole” the recipients of the vaccine, their guardians, families and community for any and
all financial and personal harm, damage and losses caused by the vaccine and any and all
harm which may be reasonably attributed to the vaccine. I understand that this is
necessary because laws to not adequately protect vaccine recipients and, in fact, put the
public at risk of uninsured harm from vaccines.

15. I am aware and understand that I must disclose all risks of vaccination prior to
administration of the vaccine and, because vaccinations do pose risks, I must allow the
recipients, guardians and families to refuse the vaccination at their sole discretion, and
that disclosure of hazards and risks does not absolve me from any responsibility, liability
or accountability for negative consequences of the vaccinations I administer.

16. If a person suffers any disease or injury at any time after vaccination and not before
vaccination and that disease or injury cannot be affirmatively attributed to any particular
cause other than the vaccination, then I agree that it is reasonable to presume that the
injury or disease was or may have been caused by the vaccination and I will so presume
and accept that theory in the absence of compelling evidence to the contrary.

17. If the vaccine recipients, guardians, family members and interested parties of the
vaccinated party should, after the vaccination, submit claims for harm, loss, damages,
injuries or disease which they reasonably suspect to be caused fully or partially by the
vaccination, then the claims must and shall be paid and delivered by the administrators of
the vaccination (above) to the claimant/s without challenge within 30 days from
 submission of each claim and any challenge to the claim/s must be made through formal
written process and/or non-binding arbitration. Refusal or obstruction of service of claim
shall not reduce obligations and shall be cause for escalated claim.

18. I am aware and understand that all administrators of vaccinations are responsible for any
emotional distress caused by their vaccinations and are liable for compensation for such
emotional distress caused to the victim/s.

19. Administrators of vaccinations hereby agree that they will allow and facilitate recording,
videotaping, documentation and investigation of all services, processes and facilities
associated with the administration of the vaccine and that administrators of vaccinations
will not refuse or obstruct that information gathering for any reason reasons such as
“privacy,” “security” or “proprietary.”

20. I am aware and understand that any failure or refusal to sign this agreement causes
suspicion of intention to do harm to the vaccinated party and others and to avoid
responsibility for potential harm that may be caused by vaccination, and I am aware and
understand that failure or refusal of signature of this agreement by any administrator of
vaccines is cause for rightful refusal of vaccination by the intended vaccination recipient
with law, code, regulations, contracts and “mandates” notwithstanding.

21. Any threat of consequence for refusal of vaccination/s, such as removal from school,
quarantine, “child endangerment,” criminal prosecution, “civil penalty” etc. is coercion,
is offensive, inappropriate, unlawful and/or violates parental rights. There is no law and
can be no valid law which would rightfully grant authority over any individual to
determine medical treatment for any other party who is in possession of their faculties.
Refusal of vaccination does not in any way imply poor judgment, diminished capacities
or social irresponsibility because there are extensive public records showing harm, injury
and death caused by vaccines.

22. I am / am not (circle one) claiming that I personally have the right and authority to force
medical treatment and vaccinations upon the party (above) whom I intend for vaccination
without his/her consent. If I claim that authority, then I will provide all legal and official
reference which bestows that authority upon me specifically against the intended
recipient of the vaccination. I understand that I must provide evidence of authority to the
satisfaction of all interested parties before the person intended for vaccination may be
vaccinated because the interested parties presume that no such authority exists nor can
exist, and, in many cases, the harm caused by vaccinations cannot be reversed.

23. I understand and agree that the person intended for vaccination is not responsible to
gather signatures on this form. The parties intending to vaccinate must acquire and share
this form, sign it and deliver it to any party intended for vaccination upon request. At
such time as the duly signed forms are delivered to the person intended for vaccination,
those agreement forms will be signed by the person intended for vaccination or by his/her
guardian and one copy will be returned to each administrator of the vaccination/s. If one
of the requested administrators above fails to sign and return the form, all agreements are
 void and vaccination is rightfully refused.

24. Refusal to sign this form is indication of deceit, bad faith and hypocrisy on the part of a
vaccine administrator who may recommend vaccination as “safe”, but, at the same time,
deny responsibility for the hazards. If vaccinations are “safe” then refusal or hesitation to
sign this form is firm indication of misrepresentation with the assertion of “safety”.

If this form is refused or not signed by any vaccine administrators listed above, then refusal of
vaccine is forthwith, rightful and refusal must be presumed and honored. Vaccination does pose
risks, therefore administration of vaccine without signature on this agreement by all parties
called for herein or and/or without fully informed consent by all interested parties constitutes
criminal assault, malpractice, intentional harm and violation of rights against the vaccinated
parties and all other parties of common interest by the administrators and providers of the
vaccine whether any harm is caused or not by the vaccination, therefore, without fully informed
consent by all interested parties, major obligations and liabilities arise from non-consensual
vaccination whether or not the vaccination causes physical injury, disease or other damage.

I agree that refusal to sign this form constitutes admission and warning to the prospective
recipient of vaccination that vaccination may cause harm and should be avoided in order to
protect the health and safety of those receiving treatment.

Refusal by any administrator of a vaccine to sign this form is grounds for the intended recipient
of the vaccine and their guardians to refuse vaccination pending the necessary safeguards and
insurance provided by the responsible party/s.

This agreement is separate and distinct from any benefit/s, or “necessities” that may be attributed
to vaccinations and vaccination programs. The public may only protected when to do so does not
violate the rights of an individual.

Any vaccine which is not fully tested and shown, by rigorous testing, trials, certifications and
general administration to be free of risk and which is accepted as such unanimously by the
scientific and medical communities, or which is not being administered and “mandated” by a
licensed physician to a consenting patient may not be administered lawfully or without major
liability and penalty for administering medicine without a license and/or without the consent of
the patient. Non-consensual medication violates the United State Constitution, medical codes of
ethics and a number of international treaties and laws.

ATTACH A DETAILED LIST OF ALL INGREDIENTS, ADJUVANTS AND

CONTAMINANTS IN THE VACCINE (PROVIDE ADDITIONAL SHEETS IF
NECESSARY, PLEASE SPECIFY PERCENT OR QUANTITY AND THE ADVERSE
AND HARMFUL EFFECTS TO A HUMAN BEING):

NOTICE: A separate agreement must be signed for each individual intended to be vaccinated
and for each separate vaccine even if separate vaccines are “combined” in one treatment.

When the party intended for vaccination is able to confirm and assure the safety and
effectiveness of the offered vaccination, receives insurance or bonding for all possible harm and
damage, receives a complete list of all ingredients, adjuvants and contaminants of the
vaccination, and receives full identification and contacts of all responsible parties (above) the
party intended for vaccination will determine whether it is appropriate, prudent, safe or necessary
to provide consent to be vaccinated.

I understand that the intended vaccine recipient accepts vaccination on the condition that it is
proven safe and effective to all reasonable expectation and insurance is provided to cover all
possible future claims of damage.

By signing this form I declare under penalty of perjury that the above is the Truth, the
Whole Truth and nothing but the Truth and I agree to accept full liability and be
professionally and personally responsible for all harm, hazard and damage and loss caused
by the vaccine and vaccination which I am administering and I waive all defenses. I also
agree that as a contracting Agent of the County, City and State where this Vaccination is
performed that the recipient of this Vaccination will be compensated $100,000,000.00 One
Hundred Million Dollars per Vaccine administered to be paid by Certified Bank Check
and/or Wire Transfer/ Direct Deposit.

Signatures, identification and contacts for responsible parties (vaccine administrators):

Authorized Officer of Vaccine Manufacturer, Name:____________________________________

Title:____________________________________

Address:____________________________________

Phone:____________________________________

Driver's license number:______________________________

Social Security Number: _______________________ (provide attached W9)

Alternate contacts and identification:____________________________________

SIGNATURE_____________________________________________

Authorized Officer of the Organization Administering Vaccinations,

Name: _________________________________________

Title:____________________________________

Address:____________________________________

Phone:____________________________________

Driver's license number:____________________________________

Social Security Number: _______________________ (provide attached W9)

Alternate contacts and identification:____________________________________

SIGNATURE_____________________________________________

Authorized and Accountable Officer of any “mandating” government agency, Name:

____________________________________

Title:____________________________________

Address:____________________________________

Phone:____________________________________

Driver's license number:____________________________________

Social Security Number: _______________________ (provide attached W9)

Alternate contacts and identification:____________________________________

SIGNATURE_____________________________________________

Individual Administering the Vaccination to the Vaccine Recipients (Nurse, Healthcare Provider or

Other, Name:____________________________________

Title:____________________________________

Address:____________________________________

Phone:____________________________________

Driver's license number:____________________________________

Social Security Number: _______________________ (provide attached W9)

Alternate contacts and identification:____________________________________

SIGNATURE_____________________________________________

Elected officials, bureaucrats and enforcement personnel supporting “mandate” of medical treatment
and/or vaccination (attach additional sheets as necessary):

Name:____________________________________

Title:____________________________________
Address:____________________________________

Phone:____________________________________

Driver's license number:____________________________________

Social Security Number: _______________________ (provide attached W9)

Alternate contacts and identification:____________________________________

SIGNATURE_____________________________________________

When filed return to:

__________________________
__________________________
__________________________

JANE HENRIETTA DOE ESTATE

Office of the Executor/ Executrix/ Administrator
123 Any Address
Any City, State, Zip
Certified Mail No.____________________________

NOTICE & AFFIDAVIT OF REFUSAL OF VACCINE FOR CAUSE

& WAIVER OF BENEFITS & PRIVILEGES
Notice to Agent is Notice to Principle
Notice to Principal is Notice to Agent

I True name here (i.e. John-Henry: Doe) declare and state:

I hereby refuse any and all vaccinations for cause and the following FACTS:

FACT: I do not know what is in your vaccine.

FACT: I do not believe your vaccine is safe.

FACT: many vaccines have been found to contain toxic adjuvants and toxic foreign materials.

FACT: toxic contamination is present in vaccines which are easily preventable with current
technology. This suggests intentional contamination of vaccines with toxic agents.

FACT: many vaccines are not effective and actually cause the ailment they are purported to
mitigate.

FACT: Adjuvants 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.

FACT: Vaccine death and injury statistics and information are suppressed by media which
receives billions of dollars in pharma advertising annually.

FACT: 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.

FACT: Vaccines kill hundreds of thousands of people per year.

FACT: 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.
FACT: Vaccines are so hazardous that the vaccine industry lobbied for, and received immunity
from the harm vaccines are causing.

FACT: Taxpayers and governments have paid billions of dollars to families who's members were
injured or killed by vaccines.

FACT: 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.

FACT: Most vaccines have not been tested or proven safe.

FACT: Under current law all physicians and healthcare workers must have my consent to
administer medicine to me.

FACT: My consent is hereby denied and refused.

FACT: I know that if someone is not a doctor, such as an elected official or public servant, 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.

FACT: It is against my deeply held religious convictions and creed to be vaccinated or have
my children vaccinated let alone be forced to.

FACT: Anyone who claims privilege to inject materials in my body without my consent is my
enemy and is criminal.

FACT: 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.

FACT: 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.

FACT: 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.

FACT: You can NOT name every ingredient in your vaccine.

FACT: You can NOT predict the future physical and side effects of each of those
ingredients.

FACT: You can NOT predict the consequences of combining those ingredients.

FACT: You have NOT offered to personally take full responsibility to pay for any harm
your vaccine causes.

FACT: You do not have the slightest authority or privilege to forcibly administer vaccines.

I hereby waive ANY and ALL benefits and privileges attributed to the creation of the ALL
CAPS NAME HERE ens legis, cestui que trust, Trust, trade-name corporate fiction.

I declare under Penalty of Perjury WITHOUT the UNITED STATES that the above is the
Truth, the Whole Truth and nothing but the Truth to the best of my firsthand knowledge,
OVERSTANDING and deeply held religious convictions and creed.

By: ________________________________ __________________

Authorized Representative Date

Important Notes:
DO NOT BE AFRAID. DO NOT LET FEAR ROCK YOU TO SLEEP!

All of these documents should be sent together as a PACK in one envelope via certified mail return
receipt. You can call it your NOVAC PACK.

What Can You Do?

Draft the above and send to Governor, Mayor, Sheriff and Chief of Police, ACLU, U.S.
Attorney for Your District, Congressman/Woman/Senator/Attorney General with the above
document package:

Important Addresses:

Federal Tort Claims Act Section

Torts Branch, Civil Division
U.S. Department of Justice
P.O. Box 888
Benjamin Franklin Station
Washington, DC 20044

Important Web Links

Federal Tort Claims Act

Online Fillable Federal Criminal Complaint – Fill it out online and print it or save it as a PDF.

IRS Form W9 - Fill it out online and print it or save it as a PDF. Tip: You would be the “requester” on
this form. You give it to whomever you need to have them provide and “certify” the SSN/TIN or EIN.