AFFIDAVIT

(We/I), _________________________, Sui Juris, Free, Natural Flesh and Blood Human Being, state Citizen of the California Republic.
Be it known to all courts, governments, and other parties that:

Being (a person/people) of Strong Christian Morals, it is against (our/my) Deep, Sincerely Held, Religious Convictions to accept the injection of any foreign
substance into (my Body/our Bodies) or the (Body/Bodies) of (my/our) (Child/Children). This includes, but is not limited to, any and all, Vaccinations, Shots,
Tests for Diseases, Oral Vaccines, Epidermal Patches and in any other way that Live or Killed Bacterium, Viruses, Pathogens, Germs, or any other
Microorganisms, may be introduced into or upon my body or any of my children’s bodies.

This written statement to exempt (my/our) newborn child from any immunizations, PKU & other testing, and the Vitamin K shot, because (I/we) hold
genuine & sincere personal religious beliefs which are inconsistent with these medical procedures & experimentation. The practice of vaccination and the
injection of any foreign substance is contrary to (my/our) conscientiously held religious beliefs and practices, and violates the free exercise of (my/our)
religious principles.

The Hepatitis-B vaccine protects against a disease that is only transmitted through multiple sexual partners or street IV drug users and therefore usurps
(my/our) parental authority to condemn such activity in my/our child/children. The acceptance of this vaccine promotes sexual promiscuity and immoral
behavior in direct contradiction to the teachings of (my/our) faith. The prescribing information on Vitamin K shot states that fatalities are an adverse
reaction according to the Merck pharmaceutical package insert. A conflict arises because my religious convictions are predicated on the belief that ALL
life is sacred. God's commandment "Thou Shall Not Kill" applies to the practice of injection of carcinogenic substances that can kill.

(We / I) {First and Last name(s)}, as the {(parent (s) / guardian(s)}of _________________________(name of newborn child) (are/am) exercising
(our/my) rights under the First Amendment of the US Constitution and Cal Health & Saf Code § 120365 and 17 CCR § 6051 to receive Religious
Exemption from Vaccination.

Applicable law has been interpreted to mean that a religious belief is subject to protection even though no religious group espouses such beliefs or the
fact that the religious group to which the individual professes to belong may not advocate or require such belief. Title VII of the Civil Rights Act of 1964
as amended Nov. 1, 1980; Part 1605.1-Guidelines on Discrimination Because of Religion.

Our Creator Yahweh is the only source of protection of my body and that of my family that I can accept.

(I/We) affirm that vaccination & injections of any foreign substances and proteins conflict with (my/our) religious beliefs as stated above. Therefore,
(I/we) would request that you accommodate (my/our) religious beliefs and practices by exempting (my/our) newborn child from any vaccination or
injections of any kind.

Rest assured that (our/my) family and (I/we) do practice a form of immunization that keeps our immune systems strong and is in keeping with Biblical
principles.

Further Affiant Saith Not

The use of notary below is for identification only, and such use does NOT grant any jurisdiction to anyone.

Subscribed and sworn, without prejudice, and with all rights reserved, (Print Name Below)

_______________________________________________________________,
Principal, by Special Appearance, in Propria Persona, proceeding Sui Juris.

_______________________________
Signature of Affiant

ACKNOWLEDGMENT

state of California

county of _________________:

On this _______ day of ______________, 200___, before me

personally appeared __________________________________, to me known to be the person described in and who executed the foregoing instrument and
acknowledged that he executed the same as his free act and deed, for the purposes therein set forth.

_______________________________________
(Notary Public)

My Commission Expires ______________________________, 200___