John H. Smith c/o 123 Main St.

Anytown, California state non domestic without th

e US
Issue date: February 11, 2013 Bond number: 123 456 789 876 543
Rosa Gumataotao Rios, Secretary of the US Treasury REGISTERED MAIL The United St
ates Department of the Treasury RETURN RECEIPT REQUESTED 1500 Pennsylvania Ave.
REGISTERED NO 123 456 789 876 543 Washington, DC 20220 PRIVATE BOND FOR SET OFF
NON NEGOTIABLE Value of Bond is Unlimited Re: CERTIFICATE OF LIVE BIRTH #12345 A
CCEPT FOR VALUE and EXEMPT FROM LEVY DEPOSIT TO US TREASURY AND CHARGE TO JOHN H
SMITH ID 123456789
Attention: Rosa Gumataotao Rios, Respondent Enclosed, the undersigned, John H. S
mith herewith accepts for value the enclosed bond Certificate of Live Birth, No.
12345 and all endorsements front and back, being the only legitimate acceptor o
f said bond, being the only party to have put any value into said bond, being th
e contributing beneficiary of the same. This is in accordance with Uniform Comme
rcial Code and House Joint Resolution 192 of 5 June 1933, and UCC 1-104 and UCC
10-104. BOND ORDER Please deposit this bond to an account bearing the Registered
Mail Number 123 456 789 876 543 for future identification purposes and to be us
ed as a set off account against any bills, taxes, or claims, and the like agains
t John H. Smith as listed on the Certificate of Live Birth, No. 12345 or any bil
ls, taxes, or claims, and the like against the JOHN H SMITH 123456789, debtor to
John H. Smith, Secured Party, see enclosed UCC 1 Financing Statement of said cl
aims to have been â acceptedâ and endorsed by John H. Smith. Please adjust any bills, tax
es, or claims and the like against the John H. Smith [See Certificate of Live Bi
rth] or the JOHN H SMITH 123456789 adjust to zero, charge, settle, and close any
such account and return the interest to the principal JOHN H SMITH 123456789 at
the above post location. Rosa Gumataotao Rios, the Secretary of the Treasury, t
he United States Department of the Treasury shall have Three [3] days from the d
ate of receipt of this Bond, as witnessed by the Date of Receipt affixed to the
USPS Domestic Return Receipt to dishonor this Bond by returning this Bond to the
Principal at the stipulated mailing address by non domestic post. Failure to re
turn the Bond as stated shall constitute Acceptance and Honoring of the Bond and
the Associated transactions, in accordance with the Law, by Rosa Gumataotao Rio
s, the Secretary of the US Treasury, and The United States Department of the Tre
asury all of the Terms and contained herein. This Bond shall be ledgered as an a
sset as best suits the needs of The United States Department of the Treasury. Th
is Bond expires at the moment the John H. Smith expires.
__________________________ John H. Smith â Principal Exemption ID# 123456789 c/o 123
Pine Street Anytown, California state non domestic without the US
__________________________ James L. Jones â Surety #1 Exemption ID# 123456789 c/o 12
3 Balsa Street Anytown, California state non domestic without the US
__________________________ Mary A. Brown â Surety#2 Exemption ID# 123456789 c/o 123
First Street Anytown, California state non domestic without the US
Witness #1:________________________________ John A. Doe c/o 123 Main Street Anyt
own, California state non domestic without the US
Witness #2: ________________________________ Jane B. Doe c/o 123 Main Street Any
town, California state non domestic without the US