Affidavit Number: (       )                                                                                                                Dist. No. (         )

(Optional Information) Height: ______ Weight: ______ Hair Color: ______ Eye Color: ______ Gender:

Mailing Location:                                                                                                                Postal Zone (Zip)

City: ________________________ County: _________________ Land District of Domicile:

2.     I was born in _________________________, ___________________________, _____________________,
                                                City                                                 County                                 State/Republic

        _________________________________, on _____________________________.
                        Country/Nation                                                     Date

3.    I have no disabilities which would prevent me from making this affidavit.

4.    I am a sovereign, freeman character, who lives and desires living, operating and conducting my
       affairs under the Common Law in the Republic of Texas and I currently domicile in ___________
        ____________________________, County, Republic of Texas.

5.    I have never knowingly, intentionally or voluntarily, become a citizen of any de facto nation or
       corporate entity, and am revoking all powers of attorney and contracts with any State, nation or
       corporate entity, to wit,  I am renouncing any such citizenship and it's implied contracts and
       benefits.

6.    This expatriation affidavit is being made under the intent expressed in the "Act concerning the
       Rights of American Citizens in foreign States," passed in 1868 by the Congress of the united States
       of America, assembled on July 27, 1868, and set forth in the United States at Large, Volume 15 at
       page 223 and 224, wherein the claim of foreign allegiance is promptly and finally disavowed.

7.     I am not wanted for, or under indictment for, any crime in Texas or abroad under the Common
        Law.

8.    I am attesting my support and defense for the Constitution and Laws of the Republic of Texas and
       am choosing the Common Law as my jurisdiction and venue.
 

Date: _______________________                                                                              Mark (Sign Name)

                            Witness                                                                                                  Witness

(Optional) Height: ________ Weight: ________ Hair Color: ________ Eye Color: ________ Gender:
(Optional) Mailing Location: Postal Zone (Zip)

(Optional) City: _________________________ County : ___________________ Land District of Domicile:
(Optional) Telephone#:                                    Fax #:                                         E-Mail:

Private Identification Number: _____________________ Affidavit Number: (               )  Date:
                                                          (Self Assigned 6 Digts)                                       Dist. No.