Notice of Statement of Medical/Religious Exemption

To whom it may concern:

I, ____________________________ am exempt from unsolicited, unnatural Immunization, injection or consumption of vaccines, inoculations, Masks and Distancing Requirements. This is my exemption from Immunization, Masks and Distancing Requirements:

My religious convictions or medial conditions are protected by the Constitution of United States of America 1789 (rev. 1992), First Amendment, the Bill of rights, Title VII of the Civil Rights Act of 1964, United States Code 42 title II Civil Rights Act, Subsection 2000 (a), HIPPA Laws, American Disabilities Act Title III and HITECH Act (Section 13410(e). 42 U.S.C. § 1983 allows people to sue the government for civil rights violations. It applies when someone acting “under color of” state-level or local law has deprived a person of rights created by the U.S. Constitution or federal statutes.

My religious convictions and medical conditions are private, confidential and that privacy by law prevents your questions, interrogation or investigation of either.

There is no evidence that I am a direct threat to the health and safety of others therefore my rights STAND.

  1. HIPPA Laws, HITECH Act (Section 13410(e) (1) make it illegal to inquire of the patient their specific health reasons for objecting to taking an injection vaccine or wearing a mask. Since the introduction of these HIPPA laws, fines can vary from $50,000 to $1,500,000 per event, even as criminal charges. ADA (American Disabilities Act Title III and HIPPA Laws, HITECH Act (Section 13410(e) no person is required to disclose physical or mental reasons for any medical condition. Businesses/schools can be fined up to $75,000 for the first offense and up to $150,000 for subsequent
  2. The First Amendment to the U.S. Constitution says that everyone in the United States has the right to practice his or her own religion, or no religion at all. “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof…”

The Establishment Clause of the First Amendment prohibits government from encouraging or promoting (“establishing”) religion in any way. The Free Exercise Clause of the First Amendment gives you the right to worship or not as you choose. The government can’t penalize you because of your religious beliefs.

  1. If you do not accept my Medical/Religious Exemption, then you are conducting yourself under Color of Law in violation of Title 18 USC 241, 242 and other titles affording me constitutionally secured, guaranteed and protected free exercise of rights, and your policies are in violation of federal anti-discrimination laws, including but not limited to US Civil Rights Act of 1964 and the Americans with Disabilities Act of 1990, and that requiring me to wear a face covering as a visible symbol of my vaccination (medical) status will subject me to harassment, discrimination, censure or retaliation of many kinds from my superiors, peers, clients or the public.

Any disregard of my God given, constitutionally guaranteed rights, privileges, or Liberties will cause you to lose your immunity to prosecution because infringement on these listed rights are against the law in every state of the United States.


Sworn Statement patterned per 28 U.S.C. 1746 (1):

“I declare under pain and penalty of perjury under the laws of the (organic) United States of America that the foregoing is true and correct. Executed on August 30, 2021.

With All Rights Reserved,






Printed  Name     ______________________, in propria persona

                    UCC 1-308 without prejudice