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September 13, 1978



I, John Henry Doe, nunc pro tunc, a living, breathing man, make this rescission,

termination, rejection, and waiver of limited liability benefits voluntarily, freely and with reservation of all rights without prejudice.

March 03, 2006
,under agency


c/o General Delivery

Minneapolis, Minnesota state

c/o 12121 Far Away Street

Blaine, Minnesota state [55449]


united States of America

c/o 999 Pure Gold Street

Minneapolis, Minnesota state [55405]

I, John Henry Doe, nunc pro tunc, a flesh and blood, living, breathing, sentient being, hereby make this Rescission, Termination,
Rejection and Waiver of limited liability insurance scheme benefits voluntarily, freely, and with Reservation of all Rights and Defenses
Without Prejudice, and state the following:
At the time of application for limited liability insurance benefits and other benefits via an SS-5 form for Social Security Number
123 45 6789, I was unable to contract, having no knowledge of the terms and conditions, reciprocity requirements and the like, undisclosed
governing laws, principles and doctrines, or implied terms of such a contract, being unconscionable, in that it provides no equal exchange
of consideration, and cannot be made valid for Failure of Consideration. The SS-5 is an Adhesion Contract and by its very nature, it fails
on its face whereby it sets forth no terms, no conditions, no reciprocity requirements, therefore it is an Unconscionable Contract, Ultra
Vires by nature.
Whereas, I nunc pro tunc, Rescind, Terminate, Reject, Forfeit and Waive any and all Benefits derived therefrom; and, I asseverate that
any and all funds received and/or taken from me, by the Social Security Administration have been done so under fraudulent pretenses,
inducement of fraud and the like, whereby the Social Security Administration its agents and principals, have no valid bona fide signature of
John Henry Doe, therefore any and all funds held by the Social Security Administration under COLOR OF AUTHORITY and/or COLOR
OF OFFICE for account number 123 45 6789, Fictional entity Name JOHN HENRY DOE, must immediately be refunded in full
immediately, anything less is fraud; and,
I, John Henry Doe, nunc pro tunc, state for the record, that I am not a UNITED STATES Citizen or National, Fourteenth Amendment
Citizen, United Nations Citizen, State of _______ Citizen, nor any Citizen at all, nor that I am an Officer, Agent, or Employee of the
UNITED STATES, nor that I am a beneficiary of any compelled benefits scheme arising out of any contract, trust, or agreement with the
I am a de jure man on the land, first appearing as John Henry Doe on the 31st day of July, 1934, at Your county, California state, and no
witness has testified and no record exists that establish any fact that I have a fiduciary duty or liability for JOHN HENRY DOE. If
national citizenship of John Henry Doe has been assumed or concluded by construction, mistake, or other means, this request for
withdrawal constitutes a formal withdraw and Notice of Withdrawal of such status.
_______________________________, without recourse, under agency

Dated: _______________