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 to 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 at any time 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 my rights as a legal and lawful citizen of the United States of America to
participate in or receive any further benefits from the above Stated Agencies.
4. I certify that 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 ___________, 2009.
_____________________, Affiant
Social Security Number ______________________
Subscribed and sworn to before me by the Affiant, _____________, this _____ day of ____________, 2009.
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 to 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 at any time 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 my rights as a legal and lawful citizen of the United States of America to
participate in or receive any further benefits from the above Stated Agencies.
4. I certify that 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 ___________, 2009.
_____________________, Affiant
Social Security Number ______________________
Subscribed and sworn to before me by the Affiant, _____________, this _____ day of ____________, 2009.
NOTARY PUBLIC
MY COMMISSION EXPIRES:
MY COMMISSION NUMBER:
Put Up or Shut Up
