AFFIDAVIT

Comes now, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being, state Citizen of the California Republic. Be it known to
all courts, governments, and other parties that:

Being a person of Strong Christian Morals, it is against my Deep, Sincerely Held, Religious Convictions to accept the injection or application of any foreign
substance into my Body, or the Body of my Husband, or the Body of my Children. This includes, but is not limited to, any and all, X-Rays, Vaccinations,
Shots, Tests for Diseases (TB tests), Oral Vaccines, Epidermal Patches and in any other way that Radiation, Live or Killed Bacterium, Viruses, Pathogens,
Germs, or any other Microorganisms, may be introduced into or upon my body.

This written statement to exempt myself from the immunization requirement, and the Mantoux (PPD) Tuberculin Test, because I hold genuine and
sincere personal religious beliefs which are inconsistent with these medical procedures. The practice of vaccination and the injection of any foreign
substance is contrary to my conscientiously held religious beliefs and practices, and violates the free exercise of my religious principles.

The Hepatitis-A vaccine containing MRC-5 is obtained from human babies that were electively aborted. WI-38 was created from the tissue of an
aborted fetus and is used for the rubella portion of the MMR-II vaccine. RA 273 was created from the tissue of an aborted fetus, and is used for MMR-
II vaccine. A conflict arises because my religious convictions are predicated on the belief that all life is sacred. God's commandment "Thou Shall Not
Kill" applies to the practice of abortion. The acceptance of these vaccines promotes abortion and violates the Sixth Commandment of "Thou Shall Not
Kill". The Hepatitis-B vaccine protects against a disease that is only transmitted through multiple sexual partners or street IV drug users and therefore
usurps my parental authority to condemn such activity in my child. The acceptance of this vaccine promotes sexual promiscuity and immoral behavior in
direct contradiction to the teachings of our faith.

Applicable law has been interpreted to mean that a religious belief is subject to protection even though no religious group espouses such beliefs or the
fact that the religious group to which the individual professes to belong may not advocate or require such belief. Title VII of the Civil Rights Act of 1964
as amended Nov. 1, 1980; Part 1605.1-Guidelines on Discrimination Because of Religion.

The Lord Jesus Christ and Our Creator are the only source of protection of my body and that of my family that I can accept.

I affirm that vaccination & injections of foreign proteins, and poisonous x-rays (radiation), conflict with my religious belief as stated above. Therefore, I
would request that you accommodate my religious beliefs and practices by exempting me from the employment vaccination and/or TB testing
requirement.

Rest assured that my family and I do practice a form of immunization that keeps our immune systems strong and is in keeping with Biblical principles.

Further Affiant Saith Not

The use of notary below is for identification only, and such use does NOT grant any jurisdiction to anyone.

Subscribed and sworn, without prejudice, and with all rights reserved, (Print Name Below)

_______________________________________________________________,
Principal, by Special Appearance, in Propria Persona, proceeding Sui Juris.

_______________________________
Signature of Affiant

ACKNOWLEDGMENT

state of California

county of _________________:

On this _______ day of ______________, 200__, before me

personally appeared __________________________________, to me known to be the person described in and who executed the foregoing instrument and
acknowledged that he executed the same as his free act and deed, for the purposes therein set forth.

_______________________________________
(Notary Public)

My Commission Expires ______________________________, 200___