Bureaucracy Encounter Form
You have requested certain information or action of me. As you are a Public Servant,
and in order for me to better facilitate your request, I require certain information for mine
own records (under Title 5, USC).
When you have filled out this form in triplicate, I will then consider your request.
Fill out completely a separate form in triplicate for each request of me you have made
or choose to make. If additional room is needed, use another sheet of paper.
Refusal to fill out this form and/or refusal to sign this form acknowledges and
acquieses on your part no authority or jurisdiction with which to proceed.
Today's date: ___/___/___ Location: ______________________________________________
Your name: __________________________________________________________________
Agency(ies) you represent: _____________________________________________________
Your business address: c/o ______________________________________________________
State (two letter State initials not accepted): _____________________________________
Postal code: [ _________-9999 ] Telephone number: _______________________________
Your badge/identification number: ______________________________
Your Social Security number: ___________________________________
Your date of birth: ____________________________________________
Your annual salary: ____________________________________________
Your supervisor's name: ________________________________________
Supervisor's telephone number: _________________________________
Describe your request in detail: _______________________________________________________________
Are you required to make this request? YES / NO (Circle one)
If so, what person or agency required it of you? ____________________________________
Are you authorized to make this request? YES / NO (Circle one)
If so, what person or agency authorized you? _______________________________________
State what statute, and what section and/or subsection(s) of that statute authorizes you to make this request:
State which portion of the state and/or national constitution authorizes you to make this request:
Have you filled out a form like this for me in the past? YES / NO (Circle one)
When? Exact dates: ___________________________________________________
What will be done with the information you collect? ________________________________________________________________________
Is this request part of a criminal investigation? YES / NO (Circle one)
Will this become part of a criminal investigation? YES / NO (Circle one)
I swear (or affirm) under penalty of perjury under the law of these united states of America that the foregoing is true and correct. I affix my signature with prejudice and I do so voluntarily and with full intent.
Refusal to sign acknowledges on your part that no authority or jurisdiction exists
with which to proceed.
About The Author
Charles Curley has been working as a self-employed software engineer, writer, and instructor since 1999. To obtain more information, see http://home.earthlink.net/~realbadger/jursdfrm.txt.
Claire Wolfe is a writer, and her most recent works are The Freedom Outlaw's Handbook, 101 Things to Do 'Til the Revolution, I Am Not a Number!, Don't Shoot the Bastards (Yet), Think Free to Live Free, and (new in Fall 2005) How to Kill the Job Culture Before It Kills You.
The opinions expressed in this article do not necessarily reflect the opinion of ILW.COM.
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