Date: May 18, 2021

In the Matter of: First Middle Last

123 Happy Street
Anytown
Indiana 07777

Respondent: First Last (doctor)

HOSPITAL NAME
Hospital address

Certified Mail #

Before me, the undersigned authority, personally appeared First Middle Last, who being by me
duly sworn, deposed as follows: “I, First Middle Last, a woman and a creation of God-Almighty,
am over the age of consent, am of sound mind, and have personal knowledge of the matters
stated herein. I have created this Affidavit to establish the true facts of this matter, because this
matter lacks the standard of regularity. I declare under the penalty of perjury by the laws of the
United States of America, that I testify here, and will testify in open court, that the facts stated
herein are the truth, the whole truth, and nothing but the truth, so help me God. I have personal
knowledge of the matters stated herein and hereby asseverate, understanding both the spiritual
and legal liabilities of “Thou shalt not bear false witness against thy neighbor.”

AFFIDAVIT OF FACT

1. I, a woman, First Middle Last, claim my body, information, genetic material and
offspring are my Property.

2. I, a woman, First Middle Last, am not Property of PERSONS doing business as Doctor
Name, DOCTOR BUSINESS NAME, HOSPITAL NAME.

3. I, a woman, First Middle Last, have no obligation [contract] with PERSONS doing
business as Doctor Name, DOCTOR BUSINESS NAME, HOSPITAL NAME.

4. I, a woman, First Middle Last, have not relinquished rights to PERSONS doing business
as Doctor First Last Name, DOCTOR BUSINESS NAME, HOSPITAL NAME.

5. I, a woman, First Middle Last, create this Affidavit of Fact for the purposes of assuring
my birth plan is recognized and honored.

6. My birth plan states:

a. All procedures, medications, treatments, and exams to be performed on Mom

First Last or offspring must be explained in full and consent obtained by at least
one affiant before proceeding.

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 b. I do not consent to SARS-CoV-2 (COVID) testing for myself, my partner or my
offspring.

c. I do not consent to any vaccination, immunization, or introduction of any foreign

material or substance into or upon the body of my offspring – this includes but is
not limited to:

i. Hepatitis B vaccination

ii. Vitamin K injection

iii. Eye ointment or antibiotic

d. I do not consent to immediately rinsing, wiping or cleaning my property after

birth.

e. I do not consent to the use of a pacifier.

f. I do not consent to immediate clamping of the umbilical cord.

g. I do not consent to being separated from my property at any time.

h. I require the umbilical cord to be clamped only AFTER complete cessation of

pulsation.

i. I require possession of my placenta and associated parts upon cutting of the

umbilical cord.

j. I require my offspring to be breastfed and to receive ONLY my breast milk.

k. I require my offspring to be accompanied by me, First Last Name or Partner First

Last Name always and in all situations.

7. I hereby and herein reserve the right to amend and make amendments to this document as
necessary, in order that the wishes of myself and my partner may be ascertained and
proceedings justly determined.

Pursuant to 28 USC § 1746(1)

“...any matter is required or permitted to be supported, evidenced, established, or proved by

the sworn declaration, verification, certificate, statement, oath, or affidavit, in writing of the
person making the same, such matter may, with like force and effect, be supported,
evidenced, established, or proved by the unsworn declaration, certificate, verification, or
statement, in writing of such person which is subscribed by him, as true under penalty of
perjury, and dated, in substantially the following form:”

I declare under penalty of perjury under the laws of the United States of America that the
foregoing is true and correct. Executed on this the 18th day, of the fifth month, in the year of
our Lord and Savior, two thousand twenty-one.

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___________________________________________ First Middle Last, Affiant

Notary used without prejudice to my rights:

BE IT REMEMBERED, That on this 18th day of May in the year of our LORD, two
thousand and twenty-one, personally appeared before me, the Subscriber, a Notary Public for
the State of Indiana, First Middle Last, party to this Document, known to me personally to be
such, and he acknowledged this Document to be his act and deed. Given under my hand and
seal of office, the day and year aforesaid.

________________________________________________ Notary Public Sitting in, and for,

The State of Indiana