John Henry Doe 
c/o 123 Main Street
Anytown    [12345]
Texas

Non-negotiable 
Request for sworn statement of Novation;
Dispute of Alleged Debt; 
Challenge of Entitlement Rights;

                								   Dated: November 13, 2003
				
This written communication hereinafter “Notice” Contains this cover page, proof of service, plus six parts.

Part 1.	THREE PAGE NOTICE OF SUPERIOR ENTITLEMENT RIGHT BY ENTITLEMENT HOLDER, OR CONTROLLING CREDITOR, OR DRAWER, OR MAKER, John Henry Doe. 

Part 2.	THREE PAGE PRIVACY ACT REQUEST. (seventeen individual Privacy Act requests) 

Part 3.	TWO PAGE ENTITLEMENT HOLDER’S PRIVATE INTERNATIONAL ADMINISTRATIVE REMEDY DEMAND NO.CNH1 AND NOTICE OF RESERVATION OF RIGHT OF INITIATING ADVERSE CLAIM OR COUNTERCLAIM and CLAIM OFFICIAL OATH, OR BOND, OR SURETY. 

Part 4.	ONE PAGE VERIFICATION OF NOTICE OF RESERVATION OF RIGHT OF INITIATING ADVERSE CLAIM, OR COUNTERCLAIM, OR CLAIM OATH, OR BOND, OR SURETY. 

Part 5.	TWO PAGE ENTITLEMENT HOLDERS CONDITIONAL ACCEPTANCE, and CREDITOR NAME HERE’S OFFER OF PERFORMANCE. 

Part 6.	SIX PAGE ALLEGED CREDITOR OR ALLEGED DEBT COLLECTOR’S GOOD FAITH DISCLOSURE STATEMENT.

For:	2ND CREDITOR NAME HERE, d.b.a., an Alleged Assignee or Transferee or Alleged debt Collector, for CREDITOR NAME HERE or trustee, or broker/dealer, or securities intermediary, or custodian: 123 WASHINGTON AVE, JONESVILLE TX 98765
	
	Including all and sundry unto whom these presents do or may concern.

Re:	Written Communication by 2ND CREDITOR NAME HERE dated December 25, 2002, a copy of which is attached herewith, made fully part hereof, and incorporated herein by reference.

Part 1.	THREE PAGE NOTICE OF SUPERIOR ENTITLEMENT RIGHT BY ENTITLEMENT HOLDER, OR CONTROLLING CREDITOR, OR DRAWER, OR MAKER, John Henry Doe 

John Henry Doe or JOHN HENRY DOE, hereinafter Entitlement Holder or Controlling Creditor or Drawer or Maker, declares under the penalty of perjury under the Laws of The united States of America and of Texas Republic, being of lawful age, a competent and willing as witness that the facts contained herein are true, complete, correct, not misleading, and are the facts as far as such have been brought into my knowledge:

1.	John Henry Doe is in receipt of CREDITOR NAME HERE or 2ND CREDITOR NAME HERE’s adverse claim dated December 25, 2002, a copy of which is enclosed.

2	This Notice is a request by John Henry Doe for certified confirmation by CREDITOR NAME HERE, for any of CREDITOR NAME HERE’s existing agreement(s) granting CREDITOR NAME HERE attachment or perfection in any Entitlement, or transfer, or control right(s), if any, regarding alleged account # 123456789.

3.	John Henry Doe is not in possession of, nor has first hand knowledge of, any certified interest CREDITOR NAME HERE has over John Henry Doe or alleged account # 123456789. 

4	John Henry Doe is not in possession of, nor has first hand knowledge of, any instrument controlling or entitling or transferring right(s) CREDITOR NAME HERE has over any asset that created or funded alleged account # 123456789.

5.	John Henry Doe is not in possession of, nor has first hand knowledge of, CREDITOR NAME HERE’s instruments or documents granting certified or uncertified entitlement or transfer or control right(s) over alleged account # 123456789.	

6	John Henry Doe is not in possession of, nor has first hand knowledge of, CREDITOR NAME HERE’s ledger entries of asset(s) that are in conformity with General Accepted Accounting Principles regarding the funding of alleged account # 123456789.

7	Absent a certified rebuttal of any points herein this six Part “Notice” by CREDITOR NAME HERE or any agents or assigns, CREDITOR NAME HERE accepts all liability for the below acts and deeds, not limited by, claims and damages unto John Henry Doe in: 

a.	a set off of alleged account # 123456789 
b.	violation of Securities Exchange Act of 1934 
c.	an adverse claim found at UCC 8-105(b)
d.	violation of 31 CFR 103.35 FINANCIAL RECORDKEEPING AND REPORTING 
e.	violation of 17 CFR 240.15c1-2 Fraud and misrepresentation
f.	violation of 18 USC 1956 Laundering of monetary instruments
g.	violation of 18 USC 1957 Engaging in monetary transactions in property derived from specified unlawful activity
h.	violation of 31 USC 5324 Structuring transactions to evade reporting requirements
i.	violation of Truth and Lending Act Section 1640(h) 
j.	violation of the Uniform Deceptive Trade Practices Act 
k.	violation of Advertising Regulations
l.	violation of the Unfair Sales Act
m.	violation of the Unfair Competition 
n.	violation of 12 USCA Sec. 1831n(a)(2)(A) or 12 CFR 741.6(b) (GAAP)
o.	violation of 18 USC 513 and 514  Counterfeiting and Forgery 
p.	violation of Pro-Offering of John Henry Doe’s Investment Securities
q.	violation of 12 USC CHAPTER 2 SUBCHAPTER 4 SECTION 83 (a)
r.	violation of law by Acts of Privateering by Breech of contract or takings
s.	violation of law by Acts of collusion between CREDITOR NAME HERE and 2ND CREDITOR NAME HERE of Acts of collusion 
t.	violation of paper terrorism
u.	violation of Freedom of Information or Privacy Act at 5 USC 552 and/or 552(a)

8.	Absent a certified rebuttal of any points herein this six Part “Notice” by 2ND CREDITOR NAME HERE or any agents or assigns, 2ND CREDITOR NAME HERE accepts all liability for the below acts and deeds, not limited by, claims and damages unto John Henry Doe in: 

a.	violation of DEBT COLLECTION PRACTICES at 15 USC 1692 f (1)
b.	violation of DEBT COLLECTION PRACTICES at 15 USC 1692 e (2)(A)
c.	violation of DEBT COLLECTION PRACTICES at 15 USC 1692 e (5)
d.	violation of DEBT COLLECTION PRACTICES at 15 USC 1692 e (10)
e.	intentional representation of  fraud
f.	violation of law by Acts of Privateering by Breech of contract or takings
g.	violation of law by Acts of collusion between 2ND CREDITOR NAME HERE and CREDITOR NAME HERE of Acts of collusion
h.	violation of Freedom of Information or Privacy Act at 5 USC 552 and/or 552(a)
i.	intentional representation of erroneous claim
j.	violation of paper terrorism
k.	violation of attorney ethical standards
l.	intentional false statement of material fact or law to a third person in which silence is equivalent to making such a statement
m.	intentional non-disclosure of material facts assisting a criminal or fraudulent act by attorney’s client.
n.	intentional failure to disclose controlling legal authority in the jurisdiction known to the lawyer to be directly adverse to the position of attorney’s client
o.	intentional offering of evidence or testimony that the lawyer knows to be false

9.	Remedy: CREDITOR NAME HERE or 2ND CREDITOR NAME HERE’s or any agents or assigns omissions of or agreement by silence of a certified rebuttal of any points in this six Part “Notice”, agrees and consents to remove any interests (liens) in John Henry Doe or any property or collateral connected to JOHN HENRY DOE or alleged account 123456789 and waives any immunities or defenses in violations agreed to in number seven or eight herein-stated or any other applicable laws. CREDITOR NAME HERE and 2ND CREDITOR NAME HERE or any agents or assigns also agrees and consents to a claim of triple damages of the original dollar amount of alleged account # 123456789 to John Henry Doe with the Federal Deposit Insurance Corporation.

10.	Rebuttal: CREDITOR NAME HERE or 2ND CREDITOR NAME HERE or any agents or assigns offering a rebuttal of this six Part “Notice” must do so in the manner of this “Notice” by signing in the capacity of a fully liable man or woman being responsible and liable under the penalty of perjury while offering direct testimony.  Any direct rebuttal with certified true and complete accompanying proof must be posted into the Notary address herein within ten days.  When no verified rebuttal of this “Notice” is made in a timely manner, a “Certificate of Non-Response” serves as CREDITOR NAME HERE’s or 2ND CREDITOR NAME HERE’s judgment or consent or agreement by means of silence with all allegations of violations herein-stated or any other law.

11.	Power of Attorney: When either CREDITOR NAME HERE or 2ND CREDITOR NAME HERE fails by not rebutting to any part of this six Part “Notice” CREDITOR NAME HERE or 2ND CREDITOR NAME HERE agrees with the granting unto John Henry Doe’s Power of Attorney and all authorization in signing or endorsing CREDITOR NAME HERE or 2ND CREDITOR NAME HERE’s name upon any checks, drafts, money orders, exchanges or any other form of payment in satisfaction of any obligation of this agreement or any agreement arising from this agreement. CREDITOR NAME HERE or 2ND CREDITOR NAME HERE grants authorization unto John Henry Doe for signing any other instrument necessary for satisfying the obligation for CREDITOR NAME HERE or 2ND CREDITOR NAME HERE under this Notice and agreement. Bankruptcy cannot discharge any obligations of this agreement. Consent and agreement with this Power of Attorney by CREDITOR NAME HERE or 2ND CREDITOR NAME HERE waives all defenses and remains in effect until satisfaction of all obligations by CREDITOR NAME HERE or 2ND CREDITOR NAME HERE. 

Part 2.	THREE PAGE PRIVACY ACT REQUEST 

This is a seventeen individual Privacy Act request under 5 U.S.C. § 552a and appropriate regulations. 
This is my firm promise to pay fees and costs for locating, duplicating and reviewing the documents for information requested below. 
I am making all seventeen individual requests in the classification of “other requester.” if costs are expected to exceed $50.00 please send estimated costs. 
If some of the seventeen individual requests are exempt from release, please send those portions reasonably segregable and provide me with indexing, itemization, and detailed justification concerning the information you are not releasing. 
The information will provide knowledge and understanding of the rules and regulations of the agency, and will assist the requester relative to the policies of the agency. 
I understand the penalties provided in 5 U.S.C. § 552(a)(1)(3) for requesting or obtaining access to documents or records under false pretenses. 
I am the person making this seventeen separate requests and my signature appears below. 
Please expedite this seventeen individual Part Privacy Act request.

At this point in time: Regarding Alleged account # 123456789 at CREDITOR NAME HERE:

1	I request copies of ALL existing records or documents or BOTH that show within any file(s) of CREDITOR NAME HERE, ALL proof of shares CREDITOR NAME HERE used, of its own, to make loan # 123456789. 

2.	I request copies of any document that establishes whether CREDITOR NAME HERE is effective as the broker regarding alleged account or transaction # 123456789. 

3.	I request any documents that establish that CREDITOR NAME HERE as the creditor regarding alleged account or transaction # 123456789.

4.	I request any certified or registered name(s) and approved filing number(s) used for the funding or crediting source to alleged account or transaction # 123456789 at CREDITOR NAME HERE.

5.	I request any copy(ies) of a certified copy, front and back side(s), of any such note or document(s) used to fund alleged account or transaction # 123456789 at CREDITOR NAME HERE.

6.	I am requesting copies of all records and documents within the registry of the United States Securities Exchange Commission that show the certified or registered investment security that CREDITOR NAME HERE has an interest in alleged account or transaction # 123456789. 

7.	I request all documents that show that CREDITOR NAME HERE is the issuer or holder in due course in alleged account or transaction # 123456789.

8.	I request evidence that CREDITOR NAME HERE is effecting alleged account or transaction # 123456789 as the dealer.

9.	I request certified confirmation of alleged account or transaction # 123456789 being a security obligation of CREDITOR NAME HERE.

10.	I request certified confirmation CREDITOR NAME HERE is effecting alleged account or transaction # 123456789 in a fiduciary capacity.

11.	I request evidence that establishes CREDITOR NAME HERE is effective as the trustee regarding alleged account or transaction # 123456789. 

12.	I request certified documentation that CREDITOR NAME HERE facilitated the transfer of funds or securities as the clearing agency re alleged account or transaction # 123456789.

13.	I request evidence that CREDITOR NAME HERE facilitated the transfer of funds or securities as the custodian re alleged account or transaction # 123456789.

14.	I request a certified copy of CREDITOR NAME HERE’s Fidelity bond and any errors and omissions policy as required by law.

15.	I request a true complete copy of CREDITOR NAME HERE’s registered and filed Articles of Incorporation.

16. 	I request any documentation evidencing CREDITOR NAME HERE as a ''insured bank'' member.

17. 	Regarding alleged account # 123456789 I request all specific names of any: 

a.	Trust
b.	Trustor
c.	Grantor
d.	Trustee
e.	Beneficiary
f.	Administrator
g.	Servicer (including any and all subservicer(s) and master servicers)
h.	Issuer
i.	Confirmer 
j.	Drawer 
k.	Drawee 
l.	Beneficiary
m.	Customer
n.	Presenter
o.	Nominated person
p.	Successor of a beneficiary

When no documentation or evidence exists in ANY files or records that CREDITOR NAME HERE has, regarding the seventeen individual Privacy Act requests herein, please send a record stating that NO SUCH DOCUMENTATION OR INFORMATION EXISTS within any files or records.

When the CREDITOR NAME HERE does not maintain any of the Information or Requests please forward a copy of any portions of these seventeen individual Privacy Act requests unto the appropriate department that does and notify the requestor of the  appropriate department and that the CREDITOR NAME HERE has forwarded it accordingly.

Part 3.	TWO PAGE ENTITLEMENT HOLDER’S PRIVATE INTERNATIONAL ADMINISTRATIVE REMEDY DEMAND NO. CNH1 AND NOTICE OF RESERVATION OF RIGHT OF INITIATING ADVERSE CLAIM OR COUNTERCLAIM and CLAIM OFFICIAL OATH, OR BOND, OR SURETY 

Re:	Alleged Creditor or Alleged debt Collector’s communication, referencing dated: December 25, 2002, a COPY attached hereto.

Alleged Creditor:	CREDITOR NAME HERE	
Alleged Account No.:	123456789
Alleged Amount Due:	$10,000.00

Entitlement Holder is in receipt of Alleged Creditor or Alleged debt Collector’s presentment referenced above; a true and correct copy of which is attached hereto and referenced herein.  

Entitlement Holder hereby gives Alleged Creditor or Alleged debt Collector Notice that John Henry Doe is not refusing payment, but is making an adverse claim, dispute, and Notice that 
a)	the above referenced alleged or purported debt is not valid 
b)	Alleged Creditor or Alleged debt Collector’s alleged claim is under dispute, and 
c)	that Entitlement Holder does not take issue with the amount of the alleged or purported debt claimed but rather the lack of CREDITOR NAME HERE’s right in the alleged claim.

NOTICE OF RESERVATION OF RIGHT OF INITIATING ADVERSE CLAIM OR COUNTERCLAIM AND OF CLAIMING OFFICIAL OATH, OR BOND, OR SURETY.

When Alleged Creditor or Alleged debt Collector, either by commission or omission, 
a)	fails by not giving full disclosure unto Entitlement Holder regarding the nature and cause of Alleged Creditor or Alleged debt Collector’s alleged claim regarding the herein referenced alleged/purported debt, 
b)	makes a false representation of the character, or legal status of the herein referenced alleged/purported debt, or 
c)	makes any threat of taking any action that cannot legally be taken, in violation of Law, codified at the Fair Debt Collection Practices Act, or any other Law: Entitlement Holder reserves all right(s) of initiating a counterclaim and for claiming the official Oath or Bond or surety of Alleged Creditor or Alleged debt Collector(s) or any Principal(s), Agent(s) or Assigns of Alleged Creditor or Alleged debt Collector(s) whose acts(s) or failure(s) by not acting result in any physical, mental, or emotional injury(s) against Entitlement Holder,. 

Alleged Creditor or Alleged debt Collector is also hereby given Notice that: 
a)	Alleged Creditor or Alleged debt Collector’s unsubstantiated demands for payment, a “scheme or artifice” “caused to be delivered by mail,” may constitute Mail Fraud under State and Federal Laws. 
b)	Alleged Creditor or Alleged debt Collector’s failure by not providing the Entitlement Holder with the requisite rights in and verification, validating the above referenced alleged/purported debt within the requirements of Law as codified in the Fair Debt Collection Practices Act and the equivalent state Laws, Alleged Creditor or Alleged debt Collector tacitly agrees: 
(i)	Alleged Creditor or Alleged debt Collector has no lawful, bona fide, verifiable claim over the above referenced alleged account, 
(ii)	Alleged Creditor or Alleged debt Collector waives any or all claims against Entitlement Holder. 
(iii)	Alleged Creditor or Alleged debt Collector tacitly agrees with compensating Entitlement Holder for all costs, fees and expenses incurred in defending Entitlement Holder against this or any continued collection attempt(s) regarding the above referenced alleged account.

This is an effort toward determining a case or counterclaim against the Alleged Creditor or Alleged debt Collector and any of the attached herein questions or disclosures or statements, including any information obtained otherwise either by Alleged Creditor or Alleged debt Collector’s silence or commission or omission, shall be agreed by Alleged Creditor or Alleged debt Collector in determining the validity of such case or counterclaim against the Alleged Creditor or Alleged debt Collector. 

Part 4.	ONE PAGE VERIFICATION OF NOTICE OF RESERVATION OF RIGHT OF INITIATING ADVERSE CLAIM, OR COUNTERCLAIM, OR CLAIM OATH, OR BOND, OR SURETY. 

Entitlement Holder’s Notice and counterclaim No.:CNH1

Entitlement Holder is competent to testify and over the age of twenty-one years regarding the matters stated herein.

Entitlement Holder has first-hand knowledge of the facts stated herein.

Entitlement Holder has read the foregoing attached Notice of Reservation of Right of Initiating Counterclaim, or Claim Oath, or Bond, or Surety.

This Notice of Reservation of Right of Initiating a Counterclaim and of Claiming the judge's Oath or Bond or Surety is not being interposed for purpose of delay. 

This Notice of Reservation of Right to Initiate Counterclaim or to Claim Oath or Bond or Surety will not prejudice 2ND CREDITOR NAME HERE, d.b.a., an Alleged Creditor or Alleged debt Collector in this matter.

Entitlement Holder has not joined into any merits of 2ND CREDITOR NAME HERE, d.b.a., an Alleged Creditor or Alleged debt Collector, presentment therein.

Entitlement Holder reserves ALL attachment, or perfection, or holder in due course, or transfer, or assignment, or consignment rights of original instrument funding alleged debt.

Entitlement Holder is controlling creditor of original instrument funding alleged debt.

Entitlement Holder is maker of original instrument funding alleged debt.

Entitlement Holder is drawer of original instrument funding alleged debt.

Entitlement Holder is attaching hereto a copy of the superior Entitlement agreement held by John Henry Doe.

Part 5.	TWO PAGE ENTITLEMENT HOLDERS CONDITIONAL ACCEPTANCE, and CREDITOR NAME HERE’S OFFER OF PERFORMANCE 

John Henry Doe’s Conditional Acceptance, and CREDITOR NAME HERE’s Offer of Performance

This is an Offer tendered in good faith as full satisfaction of the claim referenced above with intent to extinguish the alleged debt, duty, obligation, or liability by Entitlement Holder herein, “John Henry Doe,” agent for and by Entitlement Holder herein, “JOHN HENRY DOE,” named in the presentment referenced above, a copy of which is attached hereto and referenced herein, and Alleged Creditor or Alleged debt Collector, has the option of either accepting this Offer, rejecting this Offer or of making objection against the mode of this Offer.

This Offer for paying that certain sum of money for Entitlement Holder by Alleged Creditor or Alleged debt Collector asserts as an alleged debt, duty, obligation or liability, in full or in agreed installments, including interest and penalties, is made dependent upon performance of Conditions Precedent, by Alleged Creditor or Alleged debt Collector, unto which Entitlement Holder is entitled by the fundamental principals of American Jurisprudence and Law, namely, presentation by Alleged Creditor or Alleged debt Collector of verification of the alleged/purported debt and the documentary evidence establishing the factual basis for Alleged Creditor or Alleged debt Collector’s claim for payment of the alleged/purported debt liability referenced within the presentment referenced above, to wit:
Validation of Alleged Creditor or Alleged debt Collector’s right to collect this alleged/purported debt by providing verification of the alleged/purported debt, including all organic or certified true agreements of assignment, negotiation or transfer of rights, or otherwise, indicating whether Alleged Creditor or Alleged debt Collector is the current owner, assignee, holder, or holder in due course of the above referenced alleged account, with evidence that Entitlement Holder consented unto said agreement in the event that the alleged agreement is a novation;
Validation of this alleged/purported debt by providing the requisite verification and organic or certified true copies of:  
1)	all relative commercial instruments and/or contracts containing Entitlement Holder’s bona fide signature (subjective theory); or, 
2)	the evidence of an exchange of a benefit or detriment (implied contract); or, 
3)	the series of external acts giving the objective semblance of agreement (objective theory); or otherwise; between Entitlement Holder and Alleged Creditor or Alleged debt Collector, that Alleged Creditor or Alleged debt Collector relies upon in making Alleged Creditor or Alleged debt Collector’s presumptive claim; The name and address of the Original Creditor; A certified copy of a judgment;

Entitlement Holder expects a response regarding this Offer within ten days of receipt hereof, not counting day of service.  Ten days is a commercially lenient and reasonable period of time, under the circumstances, because logic dictates that unless the alleged creditor is deliberately committing fraud, then the alleged creditor must have commercially reasonable basis for making a claim of alleged debt, and that evidence of this reasonable basis must be near at hand.
Entitlement Holder does not waive timeliness, however, when Alleged Creditor or Alleged debt Collector needs additional time such additional time must be requested in writing before the expiration thereof and the reasons why an extension of time is justifiable must be given in writing with good cause shown.  Only the Entitlement Holder has the power of approving any request for an extension of time by the Alleged Creditor or Alleged debt Collector.

Entitlement Holder hereby gives Alleged Creditor or Alleged debt Collector Notice that: an obligation is extinguished by an OFFER OF PERFORMANCE, made in conformity with the rules prescribed, and with the intent of extinguishing the obligation; and an offer in writing of paying a particular sum of money or delivering a written instrument or specific personal property, is, when not accepted, the equivalent of actual production and tender of the money, instrument, or property.

In the event that Alleged Creditor or Alleged debt Collector fails by not making a response regarding this Offer within the prescribed time limit for response and there is no request for an extension of time with good cause shown, then Alleged Creditor or Alleged debt Collector is tacitly agreeing, that Alleged Creditor or Alleged debt Collector has no bona fide, lawful, verifiable claim against this alleged account, that Alleged Creditor or Alleged debt Collector waives any and all claims against Entitlement Holder, and Alleged Creditor or Alleged debt Collector tacitly agrees with compensating the Entitlement Holder for all costs, fees and expenses incurred in defending Entitlement Holder against this or any continued collection attempt(s) regarding the above referenced alleged account.

Alleged Creditor or Alleged debt Collector also tacitly agrees that Alleged Creditor or Alleged debt Collector has a duty of insuring that Entitlement Holder suffers no damage against this alleged account as a result of any actions or failure by non-action the Alleged Creditor or Alleged debt Collector.  Alleged Creditor or Alleged debt Collector confesses judgment and the Entitlement Holder reserves the right of initiating a counterclaim or to claim the Oath or Bond or surety. 

John Henry Doe’s assurance of due process of law is guaranteed at Alleged Creditor or Alleged debt Collector’s agreement and consent for a claim filed with the Federal Insurance Deposit Corporation and a release of any interest (lien) of any interest in John Henry Doe or any property or collateral re alleged account # 123456789 and Alleged Creditor or Alleged debt Collector’s Fidelity Bond or Office of Risk Management or any other claim or law. 

							_____________________________										John Henry Doe
                                                
Jurat

On this day came before me the Affiant a living flesh and blood man to oath and attest and affirm the signature is true, complete, and correct on the foregoing affidavit.  John Henry Doe the undersigned, who is personally known by me or upon proper oath and identification, personally came before me, the subscriber, a notary public in and for said County and State, and Duly Affirmed the truth of the foregoing Affidavit in my presence.  The Affiant also acknowledged the signing thereof to be his own voluntary act and deed.  Signing the within instrument in my presence and for the purpose therein stated.

Signed this day________________, of____________________, ______________ at 

________________________________.

My commission expires on: ________________________

By_________________________ 				seal:___________________

Part six.  SIX PAGE ALLEGED CREDITOR OR ALLEGED DEBT COLLECTOR’S          DISCLOSURE STATEMENT

Alleged Creditor or Alleged debt Collector and the Entitlement Holder or any court of competent jurisdiction, agree that when necessary, all parties must present and disclose this nineteen page document with any and all statement(s), with certified copy’s and answers by the Alleged Creditor or Alleged debt Collector or any or all Creditor(s).  Under the Fair Debt Collection Practices Act at 15 USC §1692g, Alleged Creditor or Alleged debt Collector attaches onto this completed DISCLOSURE STATEMENT verification, i.e. “Confirmation of correctness, truth, or authenticity, by affidavit, oath, or deposition (Black’s Law Dictionary, 6th ed.) of the record relating with each of the following:” 

1.	Regarding this alleged account, does the Alleged Creditor or Alleged debt Collector have a bona fide affidavit of assignment for entering into the alleged/purported contract between the original alleged Creditor and Alleged debtor?   YES    NO
2.  	Has Alleged Creditor or Alleged debt Collector provided the requisite verification of the alleged debt as required by the Fair Debt Collection Practices Act?   YES    NO
3. 	Date said verification was provided to the Alleged debtor: ________________________
4.  	Was the verification in the form of a sworn or affirmed Oath, Affidavit, or Deposition?   YES   NO
5.  	The verification was provided to the Alleged debtor in the form of: OATH / AFFIDAVIT / DEPOSTION
6.  	Name of Alleged Creditor or Alleged Debt Collector: ________________________
7.  	Address of Alleged Creditor or Alleged debt Collector: ________________________
8. 	Name of Alleged debtor(s): ________________________
9. 	Address of Alleged debtor(s): ________________________
10.  	Alleged account Number(s): ________________________
11.  	Amount of alleged debt owed: $________________________
12.  	Date this alleged debt became payable: ________________________
13.  	Did Alleged debt Collector purchase alleged account from original alleged creditor?    YES   NO   
14. 	Date and Purchase amount: Date: ________________ Amount: $____________
15.  	Did Alleged debt Collector purchase alleged account from a previous alleged debt collector? YES   NO   
16. 	Purchase Date and amount:  Date: _______________ Amount: $_____________
17. 	By which of the following methods was the transfer of rights over this alleged account accomplished? a) assignment   b) negotiation   c) novation   d) other – explain _____________________________________________________________________
18. 	What are the terms of the transfer of rights to this alleged account?                  ________________________
19. 	Regarding alleged account # 123456789 herein stated, Alleged Creditor or Alleged debt Collector is currently the: a) owner   b) assignee   c) holder   d) holder in due course  
 e) other – explain: _______________________________________________________
20. 	When the transfer of rights over this alleged account is by assignment, what is the consideration? $________________________
21. 	What is the nature and cause of this consideration? _____________________________
22. 	When the transfer of rights over this alleged account is by negotiation, is the alleged account taken for value? YES     NO   
23. 	What is the nature and cause of this value? ___________________________________
24. 	When the transfer of rights over this alleged account is by novation, is there evidence of consent by John Henry Doe? YES   NO
25. 	What is the nature and cause of this consent? _______________________________
26. 	Does Alleged Creditor or Alleged debt Collector have knowledge of any claim(s) or defense(s) upon this alleged account? YES  NO
27. 	What is the nature and cause of the claim(s) or defense(s) upon this alleged account? 
28. 	Were there any products or services sold by the Alleged Creditor or Alleged debt Collector unto the Alleged debtor? YES NO
29. 	What is the nature and cause of these products or services? 
30. 	Does a verifiable, bona fide, original commercial instrument(s) between Alleged Creditor or Alleged debt Collector and alleged Debtor exist in which the alleged Debtor’s bona fide signature appears thereon?   YES   NO 
31. 	What is the nature and cause of this verifiable commercial instrument? ______________                           
32. 	Does verifiable evidence exist of an exchange of a benefit or detriment between Alleged Creditor or Alleged debt Collector and Alleged debtor?   YES   NO
33. 	What is the nature and cause of this evidence of an exchange of a benefit or detriment? ________________________
33. 	Does verifiable evidence exist of an external act(s) giving the objective semblance of agreement between Alleged Creditor or Alleged debt Collector and Alleged debtor?   YES   NO
34. 	What is the nature and cause of this external act(s) giving the objective semblance of agreement? ________________________
35. 	Have any charge-offs been made by any alleged creditor or Alleged Creditor or Alleged debt Collector regarding this alleged account?   YES   NO
36. 	Have any insurance claims been made by any alleged creditor or Alleged Creditor or Alleged debt Collector regarding this alleged account?         YES       NO
37. 	Have any tax write-offs been made by any alleged creditor or Alleged Creditor or Alleged debt Collector regarding this alleged account?     YES   NO
38. 	Have any tax deductions been made by any alleged creditor or Alleged Creditor or Alleged debt Collector regarding this alleged account?   YES   NO 
39. 	Did alleged creditor follow the General Accepted Accounting Principles “Matching Principle” stated under Title 12 USC § 1831n(a) as lawfully required?     YES   NO (When answered “yes”, then supply Entitlement Holder with a verified, bona fide, and certified true copy of statement of compliance as used/required by General Accepted Accounting Principles and Title 12 USC § 1831n(a)). 
40. 	Is the alleged creditor the legal owner of the organic Promissory note that created the alleged debt?  YES    NO
41. 	Was the alleged creditor’s original loan check or similar instrument the consideration that the alleged creditor loaned in order that the alleged creditor became the owner of the promissory note?   YES   NO  
42. 	Was the alleged loan given in money or was the alleged loan an order to pay? _______
43 	When this alleged loan is not verified and certified or Alleged Creditor or Alleged debt Collector, is such non-verification a false representation of the character, amount, and legal status of a alleged debt under § 15 USC 807(2)? YES   NO   If no, why not? _______________________ 
44. 	Is alleged creditor considered a National Bank?    YES   NO
45. 	Is this alleged security investment certified or registered?    YES   NO
46. 	When answer is “YES” in question 45, then please state specifically the file number, the specific location, name, address, city, state, zip code, and phone number for obtaining a certified copy of the alleged security investment.
47. 	Did alleged creditor make this loan on the security of the shares of creditor’s own capital stock?   YES   NO
48. 	When answer is “YES” in question 47, then please send certified un-counterfeited documentation evidencing the same. When answer is “NO” in question 47, then please provide the specific alleged account information evidencing the exact location of the security interest alleged creditor used to make loan # 123456789. ___________
49. 	When alleged creditor has no certified or registered security investment in alleged account # 123456789, upon what are alleged debt collection actions based? _________________________________________________________________
50. 	When there is no evidence of a security investment by the alleged creditor in alleged account # 123456789 what are the affirmative defenses against charges of fraud against both alleged creditor and 2ND CREDITOR NAME HERE’s actions? _______________

Alleged Creditor or Alleged debt Collector’s refusal or failure by not completing and returning this statement unto Notary address herein, and providing the requisite verification validating the herein referenced alleged/purported debt becomes Alleged Creditor or Alleged debt Collector’s tacit consent or agreement that Alleged Creditor or Alleged debt Collector has no verifiable, lawful, bona fide claim against John Henry Doe or the herein referenced alleged account, and Alleged Creditor or Alleged debt Collector tacitly agrees in waiving any claim or interest (lien) against John Henry Doe or the herein referenced alleged account and indemnifying and holding John Henry Doe harmless against any costs and fees incurred heretofore and hereafter related with any collection attempts involving the herein referenced alleged account. 

Alleged Creditor or Alleged debt Collector must return this Disclosure Statement completed along with all documents referenced and requested in the attached foregoing documents.  Alleged Creditor or Alleged debt Collector’s claim will not be considered and fraudulent as long as any portion of this disclosure statement is not completed and returned with the said required documents, which specifically includes the requisite verification, made under Law, codified as the Fair Debt Collection Practices Act at 15 USC §1692 et seq., which states in relevant part that, “A debt collector may not use any false, deceptive, or misleading representation or means in connection with the collection of any debt” which includes “the false representation of the character, or legal status of any debt” and “the threat to take any action that cannot legally be taken” all of which are violations of Law.  If Alleged Creditor or Alleged debt Collector does not respond as required by Law, Alleged Creditor or Alleged debt Collector’s claim will not be considered and Alleged Creditor or Alleged debt Collector agree and consent to be fully liable for any damages and release any interest (lien) or claim in John Henry Doe or alleged account # 123456789.  Please allow thirty days for processing after receipt of Alleged Creditor or Alleged debt Collector’s response.

                                                                          	_________________________________   
Official Title of Signatory	Signature for Alleged Creditor or Collector

	

Sworn and subscribed before me, on _____________ , ____________________ is before me, a notary, and attesting regarding the truth of this affidavit with his/her signature as being true, accurate, complete and correct under the penalty of perjury being of sound mind and of lawful age.

								

Jurat

On this day came before me the Affiant a living flesh and blood man to oath and attest and affirm the signature is true, complete, and correct on the foregoing affidavit.  John Henry Doe the undersigned, who is personally known by me or upon proper oath and identification, personally came before me, the subscriber, a notary public in and for said County and State, and Duly Affirmed the truth of the foregoing Affidavit in my presence.  The Affiant also acknowledged the signing thereof to be his own voluntary act and deed.  Signing the within instrument in my presence and for the purpose therein stated.

Signed this day________________, of____________________, ______________ at 
________________________________.

My commission expires on: ________________________

By_________________________ 				seal:___________________

PROOF OF SERVICE

One, John Henry Doe, a living breathing man, does hereby swear and affirm on One’s own unlimited commercial liability, that true, correct and complete copies of the Notice of Superior Entitlement Right have been served this date November 13, 2003 addressed as follows:

via Certified Mail # XXXX XXXX XXXX XXXX XXXX to:

CREDITOR NAME HERE, 
123 RIPOFF LANE
ANOTHER TOWN, TX 54321

	

By:___________________________

Jurat

On this day came before me the Affiant a living flesh and blood man to oath and attest and affirm the signature is true, complete, and correct on the foregoing affidavit.  John Henry Doe the undersigned, who is personally known by me or upon proper oath and identification, personally came before me, the subscriber, a notary public in and for said County and State, and Duly Affirmed the truth of the foregoing Affidavit in my presence.  The Affiant also acknowledged the signing thereof to be his own voluntary act and deed.  Signing the within instrument in my presence and for the purpose therein stated.

Signed this day________________, of____________________, ______________ at 

________________________________.

My commission expires on: ________________________

By_________________________