First Middle Last, )

) SUPERIOR COURT
Petitioner, FOR ) YOUR COUNTY
)
v. )
) Case No.: xxxx-
STATE OF YOUR STATE xxxx )
) AND ALL ASSOCIATED CASE NO.
COUNTY OF YOUR COUNTY ) WITH THIS
(or however the plaintiff is shown) MATTER )
)
Respondent. )
______________________________________ ) __________________________________
_

AFFIDAVIT OF FACT AND SURRENDER OF THE ALLEGED

DEFENDANT / LEGAL PERSON / LEGAL ENTITY, “FIRST MIDDLE LAST”

COMES NOW, Petitioner, First Middle of the family Last, to this COURT, being first duly
sworn upon his oath, and deposes and says:

Petitioner, First Middle of the family Last, as a self-aware, living man, hereby affirms that I am
not FIRST MIDDLE LAST. It is a “fictitious entity”. I declare that I am First Middle of the
family Last, a sovereign, living and breathing man, and not the LEGAL ENTITY / LEGAL
FICTION / LEGAL PERSON, “FIRST MIDDLE LAST”. I, First Middle of the family Last, the
living man on the land, hereby surrender the LEGAL ENTITY, “FIRST LAST”, “FIRST M
LAST”, and/or “FIRST MIDDLE LAST” by way of a certified copy of “BIRTH
CERTIFICATE” # xxxxxxxxx to this COURT in order to satisfy this matter as well as satisfy the
warrant for “FIRST MIDDLE LAST” which a certified copy is hereby attached to.

Petitioner, First Middle of the family Last, hereby demands that the COURT and/or presiding
JUDGE remove any so-called warrant for the living man, First Middle of the family Last.

The foregoing instrument is being executed under the hand and seal of the self-aware, living man
and is a voluntary act of my free-will and Deed, so help me, God.

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 Respectfully submitted

Without prejudice,

_____________________________________

First Middle of the family Last

Self-aware, living man by special appearance
Affiant, Attorney in Fact

Your County )
) ss.
State Republic
ACKNOWLEDGMENT )

On this ________ day of _________________________, 2021 before me, the undersigned

Notary, personally appeared First Middle of the family Last, known to me to be the above-signed
affiant and has acknowledged to me that he has executed the same.

Notary Signature: _________________________

Printed Name: ____________________________

Notary Seal:______________________________
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