INVOICE NO.

: <<Invoice>>
<<Date>>

“NON-NEGOTIABLE”
BILL OF EXCHANGE

Posted Certified Account Number: <<Treas_RR>>

Account Number: <<My_Treasury>>

RE: “NOTICE OF ACCEPTANCE OF DISHONOR” and

“NOTICE OF CHARGE BACK” IN ACCORD WITH UCC 3-419 and HJR-192
and REGISTERED ADJUSTMENT OF ACCOUNT

COLLATERAL LOCATION

<<Presenter>> <<Pres_St>>
All Real and Personal Property <<Pres_City>>, <<Pres_State>> <<Pres_Zip>>

Value of Bill: $_________________

Thank you for your Refusal/Commercial Dishonor, which I accept for value (all related
endorsements front and back, to include those in accord with UCC 3-419) as evidence with this
Bill of Exchange. I have directed the “Charge Back” of this Bill of Exchange to my Treasury
Direct Account #: <<My_Treasury>>, in the amount listed above, and is part of my tax estimate for
use by the Republic. The account is charged for the fees necessary for securing and registration
(for the priority exchange for the tax exemption to discharge the public liability in accord with
HJR-192) of my personal (preferred stock/unalienable rights). I have directed the command
memory of account number: <<My_Employer ID>> to charge the same to the debtor’s order or the
Secretary of the Treasury’s Order.

Until then, I am....

Very truly yours,

<<My_First>> <<My_Middle>> <<My_Last>>

<<My_Street>>
<<My_City>>, <<My_State>> <<My_Zip>>
Employer Identification No.: <<My_Employer_ID>>

Copy: Collateral
File