State of ___________________)
)ss.
County of__________________)
AFFIDAVIT
________________________, Affiant, being of lawful age and first duly sworn, states as follows:
1. I hereby surrender all my rights receive and/or participate in any Federal or State Healthcare Benefits,
Insurance, and/or Medical Services for the remainder of my life. Whereas my personal participation in any
Healthcare Plan funded or overseen by Federal or State Agencies violates my personal beliefs as a legal and lawful
citizen of the United States of America.
2. I certify that I am not now receiving nor will I ever apply for Medicare, Medicaid, Veterans Administration (VA)
or Supplemental Security Income (SSI) health benefits anytime in my life,
3. Or, if I am currently receiving any benefits from said Agencies referred to in paragraph 2 of this document, I
willingly surrender/forfeit my rights as a legal and lawful citizen of the United States of America to participate in
and/or receive any further benefits from the above Stated Agencies.
4. I certify by signing this Affidavit: (A) I am a legal and lawful citizen of the United States of America (B) I am of
sound mind and body and (C) I am signing this document of my own free will without influence or coercion from
another person or body.
5. I hereby authorize any Federal Government Agency referred to in paragraph 2 herein to receive said
Affidavit and to make this Affidavit a permanent part of my records.
Further Affiant states not. This Affidavit is dated this ______ day of ____________,2010
______________________________________ Affiant
Social Security Number _________________________
This Affidavit is dated this ______ day of _____________ ,2010
Subscribed and sworn to before me by the Affiant, _______________, this __ day of _____________, 2010
NOTARY PUBLIC
MY COMMISSION EXPIRES:
MY COMMISSION NUMBER:
)ss.
County of__________________)
AFFIDAVIT
________________________, Affiant, being of lawful age and first duly sworn, states as follows:
1. I hereby surrender all my rights receive and/or participate in any Federal or State Healthcare Benefits,
Insurance, and/or Medical Services for the remainder of my life. Whereas my personal participation in any
Healthcare Plan funded or overseen by Federal or State Agencies violates my personal beliefs as a legal and lawful
citizen of the United States of America.
2. I certify that I am not now receiving nor will I ever apply for Medicare, Medicaid, Veterans Administration (VA)
or Supplemental Security Income (SSI) health benefits anytime in my life,
3. Or, if I am currently receiving any benefits from said Agencies referred to in paragraph 2 of this document, I
willingly surrender/forfeit my rights as a legal and lawful citizen of the United States of America to participate in
and/or receive any further benefits from the above Stated Agencies.
4. I certify by signing this Affidavit: (A) I am a legal and lawful citizen of the United States of America (B) I am of
sound mind and body and (C) I am signing this document of my own free will without influence or coercion from
another person or body.
5. I hereby authorize any Federal Government Agency referred to in paragraph 2 herein to receive said
Affidavit and to make this Affidavit a permanent part of my records.
Further Affiant states not. This Affidavit is dated this ______ day of ____________,2010
______________________________________ Affiant
Social Security Number _________________________
This Affidavit is dated this ______ day of _____________ ,2010
Subscribed and sworn to before me by the Affiant, _______________, this __ day of _____________, 2010
NOTARY PUBLIC
MY COMMISSION EXPIRES:
MY COMMISSION NUMBER:
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