John-Henry: Smith

c/o USPO General Delivery

Nevada City, California state near [95959]
Non domestic Without the US

Issue date:

____________________

Jacob J. Lew, Secretary of the US Treasury

The United States Department of the Treasury
1500 Pennsylvania Ave. NW
Washington, D.C. 20220

REGISTERED MAIL
RETURN RECEIPT REQUESTED
Registered No: RE 123 456 678 US

Bond number: RE 123 456 678 US

PRIVATE BOND FOR SET OFF

NON NEGOTIABLE
Value of Bond is Unlimited
Re:

BIRTH CERTIFICATE STATE FILE NUMBER 69-123456 ACCEPTED FOR VALUE and EXEMPT FROM LEVY,
DEPOSIT TO US TREASURY AND CHARGED TO JOHN HENRY SMITH ID 123456789

Attention: Jacob L. Lew, Respondent

Enclosed, the undersigned, John Henry Smith herewith accepts for value the enclosed bond Birth Certificate, No. 69-123456 and all
endorsements front and back, being the only legitimate acceptor of said bond, being the only party to have put any value into said
bond, being the contributing beneficiary of the same. This is in accordance with, Public Policy found at House Joint Resolution 192 of
5 June 1933, Public Law found at Chapter 48, 48 Stat. 112, and the Uniform Commercial Code UCC 1-104 and UCC 10-104.

BOND ORDER
Please deposit this bond to an account bearing the Registered Mail Number RE 123 456 678 US for future identification purposes
and to be used as a set off account against any bills, taxes, or claims, and the like against John Henry Smith as listed on the Birth
Certificate, state file number 69-123456 or any bills, taxes, or claims, and the like against the JOHN HENRY SMITH 123-45-6789,
JOHN HENRY SMITH debtor to John Henry Smith, Secured Party, see enclosed UCC 1 Financing Statement, said claim(s) to have
been accepted and endorsed by John Henry Smith.
Please adjust any bills, taxes, or claims and the like against the John Henry Smith [See Birth Certificate] or the JOHN HENRY
SMITH 123-45-6789 adjust to zero, charge, settle, and close any such account and return the interest to the principal Benjamin Lewis
Ornelas 123456789 via the John Henry Smith at the above post location.
Jacob L. Lew, the Secretary of the Treasury, the United States Department of the Treasury shall have Three [3] days from the date
of receipt of this Bond, as witnessed by the Date of Receipt affixed to the USPS Domestic Return Receipt to dishonor this Bond by
returning this Bond to the Principal at the stipulated post location by non domestic post. Failure to return the Bond as stated shall
constitute Acceptance and Honoring of the Bond and the Associated transactions, in accordance with the Law, by Jacob L. Lew, the
Secretary of the US Treasury, all successors and assigns, and The United States Department of the Treasury, to all of the Terms and
Conditions contained herein.
This Bond shall be ledgered as an asset as best suits the needs of The United States Department of the Treasury.
This Bond expires at the moment the John Henry Smith expires.

__________________________

__________________________

John Henry Smith Principal

Exemption ID# 123456789
c/o General Delivery
Nevada City, California state
Non domestic Without the US

Your Surety Surety #1

Exemption ID# 123654789
c/o 1122 Boogie Woogie Ave.
Grass Valley, California state
Non domestic Without the US

Verified by #1:________________________________
Please Print Name:

Verified by #2: ________________________________

________________________________

Please Print Name:

c/o ________________________________
___________, California state [
Non domestic without the US

__________________________
Your Surety Surety #2
Exemption ID# 987654321
c/o 1123 Boogie Woogie Ave.
Some City, California state
Non domestic Without the US

________________________________
c/o ________________________________

___________, California state [

Non domestic without the US