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Affidavit of Denial of U.S. Citizenship & U.S.

National
To John F. Kerry d/b/a/ U.S. Secretary of State and all his successors and assigns or other public
officials. w
I, Family Name (aka last name), Given Name (aka first name) beneficial owner First Name,
Middle Name Last Name d/b/a/ FIRST MIDDLE LAST (ALL CAPS TRUST) hereby and
forever state, claim and declare I am not nor have I ever been a U.S. citizen. Let it be known by
all Immigration clerks and securities of states for now and forever I am not nor will I ever be a
U.S. citizen or U.S. national. You have 3 days to bring forth your proof that I am one.
I declare under the penalty of perjury under the laws of the United States of America the
foregoing is true and correct.
I have hereunto set my hand seal of office on this, _______ Day of ___________, 2016

Executed by:_____________________________
First, Last d/b/a Last, First Middle
without the United States

JURAT
State
County

)
) affirmed and subscribed
)

Subscribed and sworn to (or affirmed) before me on this _______ day of ______________

by ______________________________________, proved to me on the basis of satisfactory


evidence to be the individual who appeared before me.

_________________________________
(Signature of notarial officer)
(SEAL)

_________________________________
Printed Name