State: ________________________ County:_______________________


The undersigned, ___________________________________ hereby states that he/she is of legal age and competent to state on belief and personal knowledge that the facts set forth herein are true, correct, complete and presented in good faith. [ ] If checked, Affiant states this to be Affiant’s Affidavit of Probable Cause regarding the following criminal activity: [ ] On the ______________ day of ___________________ in the Year of Our Lord two thousand and _______________, at approximately ________________ [ ] A.M. [ ] P.M., the undersigned Affiant witnessed ________________________________ commit what I believe to be the following criminal actions: [ ] Perjury against his/her oath of office by subscribing to a material matter he/she knows (or, should have known) to be false (18 U.S.C. Sec. 1621); [ ] Subornation of perjury by procuring another to commit perjury (18 U.S.C. Sec. 1622); [ ] Treason against the American People by levying war against their Constitution or aiding its enemies (Article III, Section 3; 18 U.S.C. Sec. 2381); [ ] Insurrection against the Constitution by inciting, assisting or engaging in rebellion against the Constitutional authority of the United States of America (18 U.S.C. Sec. 2383); [ ] Sedition/seditious conspiracy by conspiring to overthrow the Constitutional government or delay the execution of a law of the United States of America (18 U.S.C. Sec. 2384); [ ] Misprison of treason by failing to report treason when so noted (18 U.S.C. Sec. 2382); [ ] Misprison of felony by failing to report commission of a felony when so noted (18 U.S.C. Sec. 4); [ ] Impeding due exercise of rights by attempting to prevent, obstruct, impede or interfere with same (18 U.S.C. Sec. 1509); [ ] Extortion by obtaining property, funds or patronage under pretense of (under color of) office (18 U.S.C. Sec. 872); [ ] Money laundering by conducting or attempting to conduct a financial transaction with the proceeds of an unlawful activity (and, counterfeit securities) (18 U.S.C. Sec. 1956); [ ] Blackmail by threatening to inform, or as a consideration for not informing, against any violation of any law for the purpose of demanding or receiving money or other value (18 U.S.C. Sec. 873); [ ] Fraud by a judge by falsifying or concealing a material fact, making a false representation, writing a false document, or having knowledge that a document is false (18 U.S.C. Sec. 1001); [ ] Making a false declaration before a United States court (18 U.S.C. Sec. 1623); [ ] Racketeering by conducting an ongoing enterprise of robbery, bribery, extortion, or threats of same (18 U.S.C. Sec. 1962); [ ] Conspiracy to offend or defraud the United States (18 U.S.C. Sec. 371); [ ] Influencing/injuring a court officer by threats or force (remember, this document is an act of court, Affiant is, therefore, an officer of de jure court process) (18 U.S.C. Sec. 1503); [ ] Bribery of a public official witness (circle one) by offering/promising something of value to influence an official act (18 U.S.C. Sec. 201);

coercing. falsifying. 1513). [ ] Impeding a matter under agency/department investigation.C. [ ] Obtain forced labor/services of a person by threat of serious harm or physical restraint (13th Amendment. 1589).S. [20 years imprisonment] [ ] Aiding / abetting slavery by holding. altering.S.S. 1658). Sec.C. obstructing or influencing any such case or contemplation by destroying.C. 1519).C. Sec.S. persuading. Sec. 1519). 878) [10 years imprisonment] [ ] Plunder money. Sec. 1116). 113). or signature and delivery of a negotiable instrument. Sec.S.C. Sec. Sec.S.C. [ ] Retaliation against a witness (18 U. removing or avoiding a court record with consequential impact on a judgment (18 U. altering. Esc. endorsement. or tangible object (18 U. [ ] Stealing. goods.C. 18 U. 18 U.C. [ ] Impeding a case filed under title 11 or in contemplation of such matter by impeding. U. Sec. [ ] Enticement to slavery by enticing.S.S. draft. [ ] Involuntary judgment by acknowledging or procuring to be acknowledged any judgment in the name of any other person not privy or consenting to the same (18 U. document.C. intimidating or offering violence to a foreign official or official guest (18 U. merchandise. 1581). 1506). 1583). mutilating. 18 U. [ ] Theft within the special maritime jurisdiction by obtaining something of value from a person or procuring the execution.C. 18 U. covering-up.C. [ ] Tampering with a witness (18 U.S. 1512). returning or arresting any person to return him/her to peonage (13th Amendment. [ ] Plunder money.S. covering-up. check or real or personal property under fraud or false pretenses (18 U. [ ] Trafficking in slaves by recruiting a person for labor/service in violation of Title 18. goods. Sec.C. obstructing or influencing any such matter by destroying. concealing.S.S. or tangible object (18 U.S. imprisoning. . or other effects from or belonging to a vessel in distress within the admiralty and maritime jurisdiction of the United States (18 U. 1025). [ ] Assaulting a foreign official by striking. falsifying. administration or jurisdiction by impeding. [ ] Enticement to slavery by ordering a person to falsely represent him/herself as a United States Citizen in violation of 18 U. 1506). [Regarding a maritime jurisdiction (also see Piracy below)] [ ] Assault within the maritime jurisdiction (18 U.C. or making a false entry in any record. Sec. 1583). altering. 1658).C. Sec. Sec. concealing.S.S. or other effects from or belonging to a vessel in distress within the admiralty and maritime jurisdiction of the United States (18 U.C. merchandise.S.S.C. 112). [ ] Involuntary bail by acknowledging or procuring to be acknowledged any recognizance or bail in the name of any other person not privy or consenting to the same (18 U.C. inducing or carrying away a person with the intent of selling the person into involuntary servitude (13th Amendment. Esc. Sec.[ ] Obstructing a criminal investigation by preventing the communication of information relating to a violation of any criminal statute of the United States to a criminal investigator (18 U. mutilating. document. or making a false entry in any record. threatening.S. Sec. irrespective of recognition by the United States (18 U. 1506).S.S. 1510) by bribery.C. [Regarding a foreign official] [ ] “’Foreign Government’ means the government of a foreign country. [ ] Extortion of a foreign official by threatening assault (18 U. Sec.S. falsifying.C.C.C. Sec. 911 (13th Amendment.

C. 1590). having ascertained that the above noted Affiant has read and knows the contents of this Verified Affidavit of Facts. WITNESS my hand and official seal. 18 U.S. a living breathing Lawful man/woman in care of mailing location: __________________________________ __________________________________ __________________________________ On this _______________ day of the __________________ month in the year of Our Lord two thousand __________. 1506) [ ] Other: Further Affiant sayeth naught.S. inveigling. decoying. Sec. [life imprisonment] [ ] Piracy on the high seas as defined in the law of nations (18 U. [ ] Kidnapping by seizing. the undersigned living breathing Lawful man/woman in this state.S. 1651).S. [ ] Piracy by committing a hostile act against a citizen of the United States on the high seas on pretense of authority from any person (18 U. 1652). We. in the year of Our Lord. 876).(13th Amendment. Signed and Sealed this __________ day of _______________.S. living Lawful man/woman ___________________________ suae potestate esse. 18 U. living Lawful man/woman . and do hereby witness the foregoing by voluntarily setting Our Hand and Sealing this Verified Affidavit of Facts. two thousand and _______. ___________________________ suae potestate esse. or carrying away and holding for ransom or otherwise a person engaged in foreign commerce or within the special maritime jurisdiction of the United States (18 U. Void where prohibited by law. All rights reserved. . [ ] Mailing threatening communications by causing to be mailed a demand for reward for the release of any kidnapped person (13th Amendment. 1201) ([ ] see Mailing threatening communications above). Sec. Sec.C.C. Sec.S. witnessed his/her execution and sealing of the same. Sec.C. kidnapping. _________________________________________ suae potestate esse Affiant.C.C. Sec. abducting. confining. [ ] Falsifying a court record (18 U.

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