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MEDICAL PHYSICIAN JURAT AFFIDAVIT

I, the undersigned living woman known as, Jane Anna Doe; do hereby affirm, certify, declare, swear, and verify
under penalty of perjury under the laws of the united States of America – pursuant to Title 28 U.S. Code § 1746
and Public Law 94-550, § 1(a) - that the foregoing medical record is true and correct to the best of my
professional medical knowledge, opinion, and memory; and that:

1. I am a professionally educated and certified medical doctor with California state certificate number _________;
2. I explicitly claim and eternally retain all of my unalienable, unviolable, imprescriptible, inherent, God-given,
and natural Rights when born;
3. I suffer no legal disabilities and have personal knowledge of the medical facts, opinions, and Truths set forth
within this instrument and, if called as a witness, shall testify completely thereto.

NOTICE TO PRINCIPAL/S IS NOTICE TO AGENT/S;

NOTICE TO AGENT/S IS NOTICE TO PRINCIPAL/S.

WITHOUT RECOURSE OR PREJUDICE / NON-ASSUMPSIT / NON-PRESUMPSIT.

All Rights Claimed and Retained: Errors and Omissions Excepted.

Govern your self according to the Maxims of Law:

- TRUTH IS EXPRESSED IN THE FORM OF AN AFFIDAVIT.
(Lev. 5:4-5; Lev. 6:3-5; Lev. 19:11-13: Num. 30:2; Mat. 5:33; James 5: 12)
- AN UNREBUTTED AFFIDAVIT STANDS AS TRUTH IN COMMERCE. (12 Pet.1:25; Heb. 6:13-15)
- AN UNREBUTTED AFFIDAVIT BECOMES THE JUDGMENT IN COMMERCE. (Heb. 6:16-17)

I come in peace, Truth, and honor.

I say here, and will verify in open court, that all herein be True;
All Rights Claimed and Retained Eternally. My word is my Bond.

Executed on this Fifteenth day of August in the Common Era year two thousand and nineteen;
nunc pro tunc praeterea preterea.

Autographed By: _____________________________________________

Jane Anna Doe - Jus Soli; Sui Juris; and Medical Doctor
[NOTE: Original is autographed in purple, wet-ink.]
LEGAL NOTICE.
The Certifying Notary is an independent contractor and a Federal Witness Pursuant to TITLE 18, PART I,
CHAPTER 73, §. 1512. Tampering with a witness, victim, or an informant. The Certifying Notary is a Deputy
Secretary of State who also performs the functions of a quasi-Postal Inspector under the Homeland Security Act by
being compelled to report any violations of the U.S. Postal regulations as an Officer of the Executive Department.
Intimidating a Notary Public under Color of Law is a violation of Title 18, U.S. Code, Section 242, titled
“Deprivation of Rights Under Color of Law,” which primarily governs police misconduct investigations. This
Statute makes it a crime for any person acting under the Color of Law to willfully deprive any individual residing
in the United States and/or united States of America. Using a notary on this document does not constitute any
adhesion, nor does it alter my status in any manner. The notary is for the purpose of providing verification and
identification only but is not a party to this claim and not for entrance into any foreign jurisdiction, or benefit thereof.

Pursuant to California Statutes at Large; Chapter 197; Section 8202:

A notary public or other officer completing this certificate verifies only the identity of the individual who signed
the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of California republic

Los Angeles County
Subscribed and sworn to before me on this 15th day of the month August, in the year of 2019;
Jane Anna Doe, has proven to me on the basis of satisfactory evidence to be the living woman
who appeared before me.

SEAL
______________________________________
Public Notary Signature

Patient Name: John Adam Doe Case Number: SSN or other identification number