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FROM:

John Henry Doe


c/o Jane Doe, notary public
1123 Main Street
Minneapolis, Minnesota state [55401]

TO:

Alberto Gonzales
Attorney General
950 Pennsylvania Avenue, NW
Washington, D.C. 20530-0001

RE:

Notice of filing of request for withdrawal from participation on SSA form


521 and Notice of withdrawal of presumption of national citizenship.

Enclosed is a copy of my Request for Withdrawal of Application (dated on or about


________________) for participation in limited liability insurance scheme benefits, that
was delivered to the Social Security Administration in ________, _____________ on
____________. Please publish notice of this request as my certificate of election to
withdrawal that application for participation. If there is a fee for such publication, please
notify me of the amount due.
Please mail back to me a receipt showing the publication locator number with date and
time of the entry.
I know of no record that supports a conclusion that I have received any profit from any
public contract/trust, and I do not believe that such a record exists. The corrected record
is hereby established and is uncompromised. I declare the accounting for 123-45-6789 is
at a zero balance and no public liabilities exist against JOHN HENRY DOE.

_______________________________
John Henry Doe, agent for
JOHN HENRY DOE

Secretary of State
Secretary of Commerce
Secretary of Transportation
US Securities and Exchange Commission
US Solicitor General
John Snow, Trustee
Minnesota Secretary of State
Clerk of Court - ____________________

__________________
date

FROM:

John Henry Doe


c/o Jane Doe, notary public
1123 Main Street
Minneapolis, Minnesota state [55401]

TO:

Condoleezza Rice
Secretary of State
U.S. Department of State
2201 C Street NW
Washington, DC 20520

RE:

Notice of filing of request for withdrawal from participation on SSA form


521 and Notice of withdrawal of presumption of national citizenship.

Enclosed is a copy of my Request for Withdrawal of Application (dated on or about


________________) for participation in limited liability insurance scheme benefits, that
was delivered to the Social Security Administration in ________, _____________ on
____________. Please publish notice of this request as my certificate of election to
withdrawal that application for participation. If there is a fee for such publication, please
notify me of the amount due.
Please mail back to me a receipt showing the publication locator number with date and
time of the entry.
I know of no record that supports a conclusion that I have received any profit from any
public contract/trust, and I do not believe that such a record exists. The corrected record
is hereby established and is uncompromised. I declare the accounting for 123-45-6789 is
at a zero balance and no public liabilities exist against JOHN HENRY DOE.
_______________________________
John Henry Doe, agent for
JOHN HENRY DOE

Attorney General
Secretary of Commerce
Secretary of Transportation
US Securities and Exchange Commission
US Solicitor General
John Snow, Trustee
Minnesota Secretary of State
Clerk of Court - ____________________

__________________
date

FROM:

John Henry Doe


c/o Jane Doe, notary public
1123 Main Street
Minneapolis, Minnesota state [55401]

TO:

Carlos M. Gutierrez
Secretary of Commerce
14th & Constitution Ave. NW, Room 5516
Washington, DC 20230

RE:

Notice of filing of request for withdrawal from participation on SSA form


521 and Notice of withdrawal of presumption of national citizenship.

Enclosed is a copy of my Request for Withdrawal of Application (dated on or about


________________) for participation in limited liability insurance scheme benefits, that
was delivered to the Social Security Administration in ________, _____________ on
____________. Please publish notice of this request as my certificate of election to
withdrawal that application for participation. If there is a fee for such publication, please
notify me of the amount due.
Please mail back to me a receipt showing the publication locator number with date and
time of the entry.
I know of no record that supports a conclusion that I have received any profit from any
public contract/trust, and I do not believe that such a record exists. The corrected record
is hereby established and is uncompromised. I declare the accounting for 123-45-6789 is
at a zero balance and no public liabilities exist against JOHN HENRY DOE.
_______________________________
John Henry Doe, agent for
JOHN HENRY DOE

Attorney General
Secretary of State
Secretary of Transportation
US Securities and Exchange Commission
US Solicitor General
John Snow, Trustee
Minnesota Secretary of State
Clerk of Court - ____________________

__________________
date

FROM:

John Henry Doe


c/o Jane Doe, notary public
1123 Main Street
Minneapolis, Minnesota state [55401]

TO:

Norman Y. Mineta
Secretary of Transportation
400 7th Street, S.W.
Washington, D.C. 20590

RE:

Notice of filing of request for withdrawal from participation on SSA form


521 and Notice of withdrawal of presumption of national citizenship.

Enclosed is a copy of my Request for Withdrawal of Application (dated on or about


________________) for participation in limited liability insurance scheme benefits, that
was delivered to the Social Security Administration in ________, _____________ on
____________. Please publish notice of this request as my certificate of election to
withdrawal that application for participation. If there is a fee for such publication, please
notify me of the amount due.
Please mail back to me a receipt showing the publication locator number with date and
time of the entry.
I know of no record that supports a conclusion that I have received any profit from any
public contract/trust, and I do not believe that such a record exists. The corrected record
is hereby established and is uncompromised. I declare the accounting for 123-45-6789 is
at a zero balance and no public liabilities exist against JOHN HENRY DOE.
_______________________________
John Henry Doe, agent for
JOHN HENRY DOE

Attorney General
Secretary of State
Secretary of Commerce
US Securities and Exchange Commission
US Solicitor General
John Snow, Trustee
Minnesota Secretary of State
Clerk of Court - ____________________

__________________
date

FROM:

John Henry Doe


c/o Jane Doe, notary public
1123 Main Street
Minneapolis, Minnesota state [55401]

TO:

Mary Kiffmeyer
Minnesota Secretary of State
180 State Office Building
100 Dr. Martin Luther King Jr. Blvd.
Saint Paul, Minnesota 55155

RE:

Notice of filing of request for withdrawal from participation on SSA form


521 and Notice of withdrawal of presumption of national citizenship.

Enclosed is a copy of my Request for Withdrawal of Application (dated on or about


________________) for participation in limited liability insurance scheme benefits, that
was delivered to the Social Security Administration in ________, _____________ on
____________. Please publish notice of this request as my certificate of election to
withdrawal that application for participation. If there is a fee for such publication, please
notify me of the amount due.
Please mail back to me a receipt showing the publication locator number with date and
time of the entry.
I know of no record that supports a conclusion that I have received any profit from any
public contract/trust, and I do not believe that such a record exists. The corrected record
is hereby established and is uncompromised. I declare the accounting for 123-45-6789 is
at a zero balance and no public liabilities exist against JOHN HENRY DOE.
_______________________________
John Henry Doe, agent for
JOHN HENRY DOE

Attorney General
Secretary of State
Secretary of Commerce
Secretary of Transportation
US Securities and Exchange Commission
US Solicitor General
John Snow, Trustee
Clerk of Court - ____________________

__________________
date

FROM:

John Henry Doe


c/o Jane Doe, notary public
1123 Main Street
Minneapolis, Minnesota state [55401]

TO:

Clerk of Court
_________ Court for __________
________________________
________________________

RE:

Notice of filing of request for withdrawal from participation on SSA form


521 and Notice of withdrawal of presumption of national citizenship.

Enclosed is a copy of my Request for Withdrawal of Application (dated on or about


________________) for participation in limited liability insurance scheme benefits, that
was delivered to the Social Security Administration in ________, _____________ on
____________. Please publish notice of this request as my certificate of election to
withdrawal that application for participation. If there is a fee for such publication, please
notify me of the amount due.
Please mail back to me a receipt showing the publication locator number with date and
time of the entry.
I know of no record that supports a conclusion that I have received any profit from any
public contract/trust, and I do not believe that such a record exists. The corrected record
is hereby established and is uncompromised. I declare the accounting for 123-45-6789 is
at a zero balance and no public liabilities exist against JOHN HENRY DOE.
_______________________________
John Henry Doe, agent for
JOHN HENRY DOE

Attorney General
Secretary of State
Secretary of Commerce
Secretary of Transportation
US Securities and Exchange Commission
US Solicitor General
John Snow, Trustee
Minnesota Secretary of State

__________________
date

CERTIFICATE OF MAILING
On _____________ I mailed to:
Alberto Gonzales
Attorney General
950 Pennsylvania Avenue, NW
Washington, D.C. 20530-0001

John Snow, Trustee


U.S. Department of the Treasury
1500 Pennsylvania Avenue, NW
Washington, District of Columbia 20220

Condoleezza Rice
Secretary of State
2201 C Street NW
Washington, DC 20520

U.S. Department of Justice


Solicitor General
950 Pennsylvania Ave., NW
Washington, D.C. 20530-0001

Secretary Carlos M. Gutierrez


Secretary of Commerce
14th & Constitution Ave. NW, Room 5516
Washington, DC 20230

Mary Kiffmeyer
Minnesota Secretary of State
180 State Office Building
100 Dr. Martin Luther King Jr. Blvd.
Saint Paul, Minnesota 55155

Norman Y. Mineta
Secretary of Transportation
400 7th Street, S.W.
Washington, D.C. 20590

Clerk of Court
United States District Court
_____________________
_____________________

Securities and Exchange Commission


Compliance Inspections and Examinations
100 F Street, NE
Washington, DC 20549
the papers identified as:
12-

Notice of filing of request for withdrawal from participation on SSA form 521
and Notice of withdrawal of presumption of national citizenship
Copy of signed, delivered, and received SSA form 521

by mailing them for John Doe by first class mail at a United States Post Office.
Dated _________
____________________________________
notary public

_____________________________
My commission expires

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