L et it be known to all,

that the undersigned, ____________, currently residing in the Republic of  ________, do on this, the ___ day of ________, 2010, disassociate from all actions and decisions made by Timothy James Turner, Charles “C.W. “ Wright and other pseudo executive members and representatives of the "Republic for the united States of America" starting on November 11, 2010, in Spring City, Utah at the Wind Walker Guest Ranch and continuing from that day forward ... FOREVER.

Inasmuch as __________, was completely unaware of the true deception that took place and I hereby rescind, revoke and invalidate any and all documents generated at the aforementioned event and subsequent documents created by the Republic for the united States of America, which may contain signatures from any residents of  ________ on my behalf. I was not present in the secretive closed door session and was not given a voice in the proceedings; therefore my opinions and desires were not lawfully represented, causing the resulting document, “Adopted 14 November 2010 , known as the “Declaration of Sovereign Intent” to the Republic for the united States of America, to be a false representation of the will of myself and “We the People” of said republic.  These actions were taken under false claim and promises and agreed to by individuals not authorized to speak for myself and others not in attendance.  There is no standing or structure as yet accepted by the people such as a lawful de jure Constitution.

I, _____________, support no claim of representation by the people present at the clandestine meeting in Utah.  I will not be responsible for any documents, statements and subsequent consequences of the actions of those who perpetrated this fraud and deception on those in attendance at this Utah retreat or those in the ______ Republic that may come later to attach their names to the aforementioned document.

Signed  and witnessed, this ____day in _______, in the year 2010 of our Lord, amen.

                                ______________________

                                                               ______________________

Witnessed and Notarized this ____ day of ______ in the year two thousand and ten of our Lord,

Jesus Christ