This is a modified version of a letter written originally for the State of Massachusetts, posted here:


Notice to agent is notice to principal

Notice to principal is notice to agent


As the living flesh and blood woman, Jane Doe, I will not endanger my life at your request; therefore, I declare the following:

1) I am aware that those ordering and/or administering vaccines have been granted immunity from liability should I suffer from a vaccine caused injury or illness. Since the Supreme Court decision Bruesewitz v. Wyeth (Feb 22, 2011), drug companies are not required to insure their vaccine products are either safe or effective. The same decision defined vaccines as unavoidably unsafe. The Vaccine Injury Compensation Trust Fund is not an acceptable alternative to me. (Reason listed below - #9)

2) Unless I receive the vaccine manufacturer's package inserts, I have not been given full disclosure regarding any vaccine. CDC or public health vaccine information sheets and/or websites are not acceptable alternatives. (Reason listed below - #4)

3) I am aware that vaccine schedules have been established by the CDC and are promoted by public health departments, the American Academy of Pediatrics and other organizations. I do not accept CDC recommendations as science-based. (Reasons listed below - #4 & #5)

4) I do not recognize the CDC as a government health advocacy organization. It is a corporation listed on Dun and Bradstreet and headquartered in the STATE OF GEORGIA, with strong ties to the pharmaceutical industry. Therefore, their recommendations are influenced by the 'fiscal' health of their corporation.

5) I do not recognize the AMERICAN ACADEMY OF PEDIATRICS nor the AMERICAN ACADEMY OF FAMILY PHYSICIANS as health advocacy organizations. They are both corporations (listed on Dun and Bradstreet) that are headquartered in the STATE OF ILLINOIS and the STATE OF KANSAS respectively, whose monetary compensation from the vaccine manufacturers contributes to the 'fiscal' health of their corporations.

6) I am aware that many physicians are paid higher reimbursement rates for administering vaccines.

7) I am aware that LEGISLATORS vote on statutes and rules for the STATE OF Name of State. As the LEGISLATORS have no medical training and can easily be influenced by drug company lobbyists and/or the CDC, I do not accept their corporate statutory mandates as science-based.

8) I am aware of multiple scientific peer-reviewed papers that have exposed the dangers of many vaccines as well as the "herd immunity myth" of 1933.

9) I am aware that the corporation HEALTH & HUMAN SERVICES, UNITED STATES DEPARTMENT OF (listed on Dun and Bradstreet and headquartered in WASHINGTON DC) determines claims paid from the Vaccine Injury Compensation Trust Fund via a secret administrative process and also profits from vaccine patents.

10) I have concluded that failure to follow the CDC recommendations about vaccination is less likely to endanger my health or life than following their recommendations.


For the reasons I have listed and more, I do not consent to the administration of any vaccine unless I am provided with the vaccine package insert, the allowance to determine if the health risks are acceptable, and if you sign a document stating that you (in your professional and personal capacity), not me, Name of person willingly accept the responsibility for any injury or illness (as defined by the International Medical Council on Vaccination), including my death that the vaccine (or medical therapy) being required of me causes.


Name:               :                                            Signature:                                                   Date:

_________________________________     _____________________________            _________


I hereby declare under penalty of perjury that the above information is complete, correct, and true to the best of my knowledge.



Subscribed and sworn to (or affirmed) before me on this_________ day of                           2021,



 By________________________________________________ , proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.

( Notary)