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U.S. Office of Personnel Management

Guide to Personnel Dala Standards

ETH

CITY AN D RACE lDFIrTfl

Fl

gFflSf'l-)FFICE

(Please read the Privacy Act Statement and instructions before.c*pf,jtEBtdl*.1

Name {Last, First, Middie lnitial)

Social Security Number

FULLILOVE,MICHAEL,A

489-76-3195

Privasy Act Statemant

Ethnicity and race information is requested under the authority of 42 U.S.C. Section 2000e-16 and in cornpliance
with th; Office of Management and Budgefs 1997 Revisions to the Standards for the Classification of Federal

Data on Race and Ethnicity. Providing this information is voluntary and has no impact on yeur employment
status, but in the instance of missing information, your employing age*cY will attempt to identiff your race and
ethnicity by visual observation.

This information is used as neces$ary to plan for equal employment opportuni$ throughout the Federal
govemment. lt is also used by the U.S. Office of Perscnnel Management or employing agenry maintaining the
iecords to locate individuals for personnel research or survey response and in the production of summary
descriptive statistics and anatytical studies in support of the function for whic*r the records are collected and
maintained, or for related worKorce studies.
Sociat Security Number (SSN) is requested under the auihcrity of Executive Order 9397, which requires SSN be

used for the purpose of unifonn, orderly administration of personnel records. Providing this information is
votuntary and failure to do so will have no effect on your employment status. lf S$N is not provided, however,
other agency sources may be used to obtain it.
$pecific lnstruclions: The two questions belft'r are designed to ideniifo your elhnicity and racs, Regnrdless of your ansrver to
question 1, go to quesfion 2.
Question t. Are You Hispanic or Latino? {A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin, regardless of race.)

ffives

[]ruo

Questioo 2. Please select the racial category or categories with which you most closely identify by placing an "X" in the appropriate
box. Check as many as apply.

RACIAL CATEGORY
(Check as many as apply)

DEFINITION OF CATEGORY
A person having origins in any of the original peoples of North and South America
(including Central America), and who maintains tribal affiliation or communtty
attachment.

fi

American lndian or Alaska Native

esian

Stacx or African American

A person having origins in any of the black racial groups of Africa.

ttative Hawaiian or Other Pacific lstander

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or
other Pacific lslands.

ffi

wnit"

A person having origins in any of the original peoples of the Far East. Southeast
Asia, or the lndian subcontinent including. for example, Cambodia, China, lndia,
Japan, Korea, Malaysia, Pakistan, the Philippine lslands, Thailand, and Vietnam.

A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.
Standard Form 1Bl
Revised August 2005 Previous editions not ugable

42 U.S.C. Section 2000e-16

NSN 7#0-01-0S9-3446

S*ltiatgry Feqlar_atrgp

ln the matter Amenciment of fulissouri Heath Division of vital records Ilegistration # 124-76-0018 i I
I, Mich:rel Anthony Fullilove nos'kuown as: Marshawn Shiloh Wijaya Sha'ui me 'el cio 3916 N
Fiorissant St.Louis I'lissouri do solemnl3,'declare in accord with: the 1931 statute r:f \&'es161p51r,
(i.l-':rl.-i,'::i-.i:,:.,r.'l:.1*i:::,:l-u' ::. j. I778 Articles of ccrnfederation ancJ pelpetual Union Articies XI, 1 B 12
Treaty' of Ghent; 17{}4 Ja.v'Ireaty: 1836 Treaiy of }Ian'akesh (Morocco) a1l recognized and va}id
treaties, constitution for the unrted siates 01'America, the I 948 Charter of the United liations, the
1975 Inter-American Declaration on the rights of Indigenous Peoples and the Unitecl Nations 2"d
decade of the world's Indigenous people, that upon discovering that rhe registration ol'a Live Birth
oi Februarl'5'h 1976. in rhe STATE CF MISSOURVMISSOURI REPUBLIC called Missouri
Repubiic was a contract between my mother and the I-I.S. Government Corporaiion who did not tell
her she was selling me, a flesh and blood child, tc rhe STATE OF MISSOURI CORPORATICN as
the Chattel PropertylSlave rvhich is a vioiarion of Hurnan Righrs, I hereb.v void the contract, ab
inrtio for fraud. Since I am a Flesh AnrJ Biood: Meianinite Cherokee Narive American Moor of
Turtle Island and of this Pianet in accord u,ith the United lriations Declaration on tire Rights of
Indigenorrs Peopies, HJR 194- iii.*.r!..{.,"*o-j:, it-:*i*sli:l,l.i.*trlj:Ur:i,:j-i11rjj.i U.s -ong."r,
Apology to Aliican Americans for Slaver1,, S, Con, Res. 26- United State Senate Apology to african
Americans for Siavery; u.s. apoiogy To Native Americans (Sec 8 i 13 of H.R.3326 Departrnent of
Defense Appropriations Act) il,'::;:l_-i::i.*:._*jj._:j:t.lglxj_ij:;}f_rljJJ.l.:lrylicd,*.i .. gpon
disccvering that Elizabeth Aiexandra Mary Windsor Mountbatien Baltenberg
IMISNOMbR, qu**,
Elizabeth III vrolated her coronation oath ( a iegally binding conrracr) of June z"d 1953. on 1i7,iy
la,
2411 at Southward Crown Court (1 English Grounds in Southrvard, London, Engiand)
Defendalt:
John Anthony Hill in the United Kingdom proved before an English jury rhat
Elizaberh Alexandra
fular,v Windsor-Mountbaften, was not the rightfui monarch and
never rvas: queenl Elizabeth is not
the rightful monarch and never was. This was a two point argument. Firstlli
Elizabeth knew- then
anC now- that she lvas crorvned on a fake coronation stone
instead of the real Stone of
Desiiny/Coronation Stone, which meant noi only rvas she never properly crovrned,
but she
knorvingly and fraudule-ntly was connin-r the Public and that is s,hy she did
noi want her coronation
televised. REGINA v.JAH (case Ref. Numtrer:T20107746) (
See
i*i:.,.:i.r-:1,,,'-r:r,i*-:,tl-.,,*:i:..::;i-r.I) I deciare that the name $IICHAEL ANTHOl,iy FL-LLILOIrE
on the registratron of the Live 6i61, is a corporation and j!{ichaetr
Anthony Fullilove, is an
Indigenous, Flesh & Blood Man- I am i{ot a corporation, artillcial p*.rou,
natural person, fictitious
entity or vessel ol the United States as defined under 18 U-S.C. 9 anrl give
I
notice Internationaiirv,
Domestically and Universally via this Declaration that I deny corporate
existence. Under
reservation of Ali My Rights Unaiienable and oiherrvise, I am: IndigenouslAutochthon
of this
planet' And I make this solemn declaration conscientioustry
believing it ro be true. and knowing tlat
this is the same force ancl effect as made under oath.

Jurat
united l{ations Declaration on the right of Inrligenous peopiesUnited l{ations Convention on
social & cultural Rights, United xations Chu.t"r, Article 55 & 56, presidential
proclamation 7500,H.J.R. 194. S. Con. Res. 26 S. 1200. HJR__I
Affirmed to and subscrjbed before me

thifiAday of Ma1,*_20
B,t'
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