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Table of Contents Note from AC ................................................................... 3 UNDERSTANDING THE LAW THAT APPLIES TO THE BIRTH CERTIFICATE .................................................................. 5 BUYER BEWARE: THE APPLICATION IS THE CONTRACT ......... 7 The Birth Certificate exists for the sole purpose for getting fiat currency and substantiating the U.S. debt. .......................... 8 Exhibit A .......................................................................... 11 Completing the Legal Portion of Your Baby’s Birth Certificate ... 12 Collecting Information Required by Federal Law .................... 12 Gathering Medical Information that is Used for Public Health ... 12 Exhibit B .......................................................................... 18 DIRECTIVE NO. 15 RACE AND ETHNIC STANDARDS FOR FEDERAL STATISTICS AND ADMINISTRATIVE REPORTING ......................... 19 (as adopted on May 12, 1977) ..................................................... 19

©2011CommonCentsConsulting.All Rights Reserved 2

Note from AC I determined a long time ago that I was not going to be a woman that sits idly and watches my people’s freedom wither away while the masses buy into an illusion of major obstacles to make adequate changes in their daily personal lives. I have the knowledge, the wisdom to apply, and the innate natural overstanding to Stop Playing. Although Katrina and Haiti did not directly affect me today it is only a matter of time that it could. In nature all we have is nature to protect us. By perpetually living in the Land of Oz and the Matrix all we have is ourselves to protect us from their architects. It is in these days of enlightenment there is an abundance of information that is being released into the atmosphere. Natural and supernatural events (many referenced by the ancients) are superimposing our perceptions and it is time to wake up and deal with the reality of our existence. So here we are with unseen shackles and nooses dangling around our throats. We are part of a cycle and this is the season that we should take heed and consider that our ignorance, robotic, trained, and conditioned thought patterns and any resulting actions that are in opposition to nature have consequences. Our natural (birth) rights are being voluntarily usurped. We are too complacent and dare to call ourselves conscious when we are dead, asleep. We have no concept of what our power is individually or collectively. I am doing these workshops to appeal to the sons and the daughters of first creation who still feel a need to be representatives of Nature. What I am proposing to eradicate is our fear in the face of the opposition to the sons and daughters of a nature that patiently waits for us to amalgamate and deviously attempts to eradicate us. I am proposing to eradicate the general hopelessness that there are no home remedies to the diseases we suffer from intermingling with Colonists. I am willing to share what has worked for me. I start with the Birth Certificate because it is my duty as a woman to take responsibility as a woman. From my perspective everything starts with the woman. We are the ones that give birth to the children, inform on them, and surrender them to the corporation plantation and utilize that status to reap financial benefits from claiming them as a fiction. In my humble opinion sisters need to STOP TALKING about anything else (it’s not relevant) and go reclaim your children! Get a hold of yourselves people. Stop complaining about the white man, the Europeans, and the Plantation if you do not want to apply the solutions to get off the plantation. By starting with the Birth Certificate I will show you how to love yourself and your children enough to protect them from someone other than your jurisdiction. After State of Mind, this is the commencement to the rejection of any type of assistance from any inorganic entities. These corporate fictions engineer crisis and solutions to entrap us into depending on them for the basic of functions like having babies, growing our own food, healing ourselves, educating ourselves, trading, and even worshiping.


We consistently contract ourselves into their corporate jurisdiction. If we avoid doing business with them what will they have? If we avoid any type of assistance from them we will raise ourselves back to our natural state, change the climate of our communities by teaching our children to be responsible for themselves. They will know that the U.S.A. or the U.S. is not their parents, not part of the human family nor party of their immediate family. They will naturally know how to support themselves and ultimately will Uplift Fallen Humanity. I am not going to spook anyone out. I am not going to get into capital letters and lowercase letters. For those who are interested in that information look to the “U.S. Government Styles Manual” for the evidence in section on “ABBREVIATIONS AND LETTER SYMBOLS” at: I am not going to go into more advanced questions of the possibilities of canceling or voiding State Issued Birth Certificate or Certificates of Birth or how to monetize them. Waste of Precious Energy. These are The Stop Playing: Common Reality Workshops. These workshops are a simple solution to keep new business (our babies) in our (their) natural birthright status and keep old business of (being bonds men and women) the same until one is ready to apply moor advanced level of solutions available. Many moor have come before me with Ecclesiastical, National and even Redemption strategies…It is up to you to do the research and choose your path. I just want you to be able to have alternative options while you are seeking. Tune in any Thursday @ 8pm EST. Log on to or Call 347.637.2270 to Listen and or Ask Questions. ~AC


UNDERSTANDING THE LAW THAT APPLIES TO THE BIRTH CERTIFICATE The so called existence of the U.S. and U.S.A. is irrelevant when we know who we are and where we are going. All of the commercial activity that so called commences with the Birth Certificate would really be null and void because we would know how to navigate the Illusionary Matrix and any consequence of using such fictional instruments would cause no harm to our actual physical bodies. We would just plug out. Much research surrounding the Birth Certificate requires comprehension of the language of presumptions and Compact Theory of Law. What it means to you is evidenced by the very fact that you are reading this workbook. This workbook would not be needed if we gave more thought to our flesh and blood, breathing, government of ourselves and We the People. For those that want to be humored: What law will you decide to use for yourself and/or child….discretionary corporate policy or our own divine and Natural Law.

PLUGGING INTO THE MATRIX "It is well settled that "United States" et al is a corporation, originally incorporated February 21, 1871 under the name "District of Columbia," 16 Stat. 419 Chapter 62. It was reorganized June 11, 1878; a bankrupt organization per House Joint Resolution 192 on June 5, 1933, Senate Report 93-549, and Executive Orders 6072, 6102, and 6246, a de facto government, originally the ten square mile tract ceded by Maryland and Virginia and comprising Washington D. C., plus the possessions, territories, forts, and arsenals. " United States - US- U.S.-USA-America Means: (A) a federal corporation . . . Title 28 USC Section 3002(5) Chapter 176. It is clear that the United States . . . is a corporation . . . 534 FEDERAL SUPPLEMENT 724. "The United States government is a foreign corporation with respect to a state." N.Y. re: Merriam, 36 N.E. 505, 141 N.Y. 479, Affirmed 16 S.Ct. 1973, 41 L.Ed. 287 "In the United States of America, there are two (2) separated and distinct jurisdictions, such being the jurisdiction of the states within their own state boundaries, and the other being federal jurisdiction (United States), which is limited to the District of Columbia, the U.S. Territories, and federal enclaves within the states, under Article I, Section 8, Clause 17." Bevans v. United States, 16 U.S. 336 (1818)

The significance of this is that, as a corporation, the United States has no more authority to implement its laws against "We the People" than does Microsoft Corporations, except for one thing -- the contracts we've signed as surety for our name on the Birth Certificate with the United States and the Creditor Bankers. These contracts binding us together with the United States and the bankers are actually not with us, but with an artificial entity, or as they term it "person" And others term the “Strawman”. The 14th Amendment created a "Federal nation" as compared to the sovereign "state nations" comprised of the 50 sovereign states of the union. This Amendment created a de facto citizenship which every American "became" through unwitting acquiescence, thereby placing them under "privilege" of such citizenship and also allegiance to, and subject under the laws to same. Case law supports this premise. Prior to the 14th Amendment "citizens of the United States" meant a "citizen" of one of the United States of America, however, this was NOT defined by Congress. Because this phrase is NOW used in the 14th amendment, this sets forth a specific terminology and can no longer mean anything else, other than a "citizen 5

of the federal government..." a "United States Citizen" naturalized as such at birth without informed consent. Previous court case law touched on this de facto entity, the "Citizen of the United States," in Ex Parte- Frank Knowles, California Supreme Court, July term - 1885. In this case the court stated that there was no such thing as a "citizen of the United States," that is, to say, there was no such thing as a citizen of the Federal State, only a citizen of one of the United States.

Section 3.19, NYC Health Code provides, in part: “. . .no person shall make a false, untrue or misleading statement or forge the signature of another on a certificate, application, registration, report or other document in paper, electronic or any other form or medium, required to be submitted or filed with the Department.” Violations shall be treated and punished as a misdemeanor and may also be subject to a fine of up to $2,000 per violation. See Exhibit A: The Birth Certificate is a permanent, legal record of your child’s birth. The New York City Department of Health requests that you answer the following questions so that the Birth Certificate can be filed by this hospital as required by the New York City Health Code.


BUYER BEWARE: THE APPLICATION IS THE CONTRACT Hospitals/ Hospices should be immediately deemed as hostile foreign territory. If you decide to birth your child’s vessel/ ship into this foreign port authority then you should do so Caveat Emptor and Buyer Beware. If you as the Captain of your child’s ship should you decide to present your Certificate of Manifest detailing the value of your ship then be prepared to fulfill the contract requirements that you agree to in exchange for the service of birthing your ship in their Port. You have a right to navigate to your ship and a right to contract. Rest assured that they have a system in place to enforce their Uniform Commercial Codes. Maritime Law. All modern day Corporate Nation States have Port Authorities which service the birthing of vessels. According to Department of Health and Human Services Office of Inspector General, “currently, 6,422 different entities issue birth certificates.” That BC is monetized on the NY Stock Exchange. Check it out…the series of red numbers printed on the BC. The stock exchange number is right on the BC. The children ships are worth monetary value to the International Bank that bought them in 1930.


The Birth Certificate exists for the sole purpose for getting fiat currency and substantiating the U.S. debt. The BC is your initial point of contract. Examine Exhibit A. The Birth Certificate determines the geo political designation of jurisdiction that now has jurisdiction over YOUR vessel you WERE navigating. This is why the Birth Certificate and our use or non use of it is very important. The question is do you have to subject yourself to using the one provided for you or do you by the very same entity that you subconsciously would rather not do business with in the first place? Contracting with a Hospital to do a service that they are required by their Uniform Commercial Code to register their services rendered is unfavorable to live organic beings. Our ships to do not manifest in their ports and therefore should not be subject to the jurisdiction of their ports. Engaging in contracts that originate in our own ports of jurisdiction is the purpose of this workbook. We have to seek to be responsible. We must do the work to maintain and expand our authority and jurisdiction over what belongs to us instead of initiating chains of extensive paperwork that consistently contract what is rightfully ours to recessive inorganic entities. Points of Contract to consider: 1. As the Captain of your shipchild do you need a Dock Agent to consult with you on how to sign your vessel over as a permanent surety and accommodation party to the Artificial U.S. debt? 2. Do you agree to register your ship’s birth in the Artificial State of an Artificial Bankrupt Union? Do you want your child’s birth title to appear as Artificial Debtor Name on the Birth Certificate Commercial Contract? 3. Are you willing to volunteer your homemade organic vessel to forever become indebted thorough bondage to the debtor U.S. who is owned by Foreign Creditors and Bankers? 4. Would you rather file your Certificate of Manifest for the birth of your shipchild at the Department of Commerce/ Bureau of the Census or would you rather keep it between you and the Original Port of Jurisdiction? 5. Would you like for your Certificate of Manifest for your shipchild to be used as Trust Instrument/ Negotiable Security Instrument that the Central Banks will become the fiduciary? 6. Would you like for that above instrument to be utilized as instant credit to benefit the World Bank ( I am not sure if you have a direct account with them and bank card), International Monetary Fund (Did not know if you have access),Bank of England etc…? 7. Are you willing to further volunteer your shipchild to the U.S. as a guarantee to the purchasers of their securities the lifetime labor and tax revenues using the Birth Certificate as collateral for payment? If you answered No to any of the above questions then let’s not waste any more energy putting your status on their records. Going forward let us not waste anymore energy classifying ourselves with the unclassified and their application contract system. A certified copy of a birth certificate is proof that your ship child birthed occurred in their port of jurisdiction and that the status and Nationality of the Ship was classified, recorded, and registered with their Port Authority State and stamped U.S. citizenship/property. M y people: Regardless of what you define yourself as or who you say you are. There is no emotion or indice in the subject or citizen status for Moors/ Muurs/ Aboriginal/ Indigenous Folk. We are not supposed to be 8

citizens (the name for their employees/ bondpersons) of a company authorized only to do business with us by way of Treaty... It is important to know our rights and immunities and our rights relative to others‌..refer to Exhibit B. Federal Directive No. 15. Our status today is dependent upon what we tell them, what, where and how we classify ourselves as on the application for the Birth Certificate. To be contracting in the first place is unfavorable and when we do we use lesser categories to describe our shipchildren. The U.S. are advanced in our lessons taught to them. They do presume to know anything. When we use their commercial paper to contract business with them we act in the capacity of experts. When we classify OUR shipchildren as members of a fleet for a defacto corporate body we are contracting as experts. If you do not create a Certificate of Manifest (Birth Certificate) for your ship (child) (precious cargo) will not be a citizen of the "United States" as described in code or statutory law, and no such de facto relationship will be created or contracted and no presumptions will exist. Your child will owe no such allegiance to the United States. Your child will not be encumbered in any way or separate from their de jure allegiance, and the Treaties in which they are protected by the authority to invoke the Constitution to which the United States and United States of America is bound. Eradication of our contracting and use of the Birth Certificate will prove that we are neither born in any possession of the "United States", nor IN the "United States" (see definition of United States under point 2), and that your child is NOT a citizen or national of the United States government. Invito beneficium non datur. No one is obliged to accept a benefit against his consent. But if he does not dissent, he will be considered as assenting. With the eradication of the contract and use of the Birth Certificate we do not dissent, and do NOT accept obligations or contracts with the "United States government," nor do we accept any benefits which would place us or our children under any contracts or obligations to the "United States government," unless such benefits are freely provided with no obligations of any kind, NO jurisdictional authority over us or our children, or NO loss of personal sovereignty or anything else important to us. With the eradication of the contract and use of the Birth Certificate we are not in the jurisdiction of the defatco corporate United States government, as a citizen or national, as far as responsibilities or owing anything unconstitutional or illegal to same. The United States government is for the protection of all American rights, and serves all Americans. As a Moorish American, we are only in relationship with the United States regarding constitutionally reserved rights to said government. All other rights we should be reserved for ourselves. Credentials like the State of Birth Certificate are not of our own origin, we receive no natural benefit and consequently creates a case for our voluntary DENATIONALIZATION or Dual Citizenship which is a status that many unknowingly but willingly purport to have.


PLUGGING INTO THE MATRIX Dual nationality, the Supreme Court has explained, is "a status long recognized in the law." Kawakita, 343 U.S. at 723. See also id. at 734 ("Dual nationality . . . is the unavoidable consequence of the conflicting laws of different countries. One who becomes a citizen of this country by reason of birth retains it, even though by the law of another country he is also a citizen of it.") (citation omitted); Savorgnan, 338 U.S. at 500 (although "[t]he United States has long recognized the general undesirability of dual allegiances[,] . . . [t]emporary or limited duality of citizenship has arisen inevitably from differences in the laws of the respective nations as to when naturalization and expatriation shall become effective"); Elg, 307 U.S. at 329 ("As municipal law determines how citizenship may be acquired, it follows that persons may have a dual nationality."). The mere assertion by an individual of citizenship in one country thus need not manifest an intention to relinquish citizenship in another country, for "[t]he concept of dual citizenship recognizes that a person may have and exercise rights of nationality in two countries and be subject to the responsibilities of both. The mere fact that he asserts the rights of one citizenship does not without more mean that he renounces the other." Kawakita, 343 U.S. at 723-24. Take a look at an excerpt of the U.S.A. Passport Application: PROOF OF U.S. CITIZENSHIP a. APPLICANTS BORN IN THE UNITED STATES: Submit a previous U.S. passport or certified birth certificate. A birth certificate must include your full name, the full name of your parent(s), date and place of birth, sex, date the birth record was filed, and the seal or other certification of the official custodian of such records. 1) If the birth certificate was filed more than 1 year after the birth: It must be supported by evidence described in the next paragraph. 2) If no birth record exists: Submit a registrar’s notice to that effect. Also submit a combination of the following: an early baptismal or circumcision certificate, hospital birth record, early census, school, or family Bible records, or newspapers or insurance files. Notarized affidavits of persons having knowledge of your birth may be submitted in addition to at least one record listed above. Evidence should include your given name and surname, date and place of birth, and the seal or other certification of the office (if customary) and the signature of the issuing official.

Notice all of the underlined words above. These are standard instruments and alternative documentation we can be using WITHOUT the assistance of any State of Entity. This is the basic info required for your own home or organic entity based documentation of where your ship birthed. Please examine Exhibit C for an example.


Exhibit A

Sample Birth Certificate Worksheet


Your Baby’s Birth Certificate The information we are requesting has several purposes including:  completing the legal portion of your baby’s birth certificate;  collecting information required by federal law; and  gathering medical information that is used for public health.

Completing the Legal Portion of Your Baby’s Birth Certificate It is very important that the names, dates of birth, and places of birth are correct. Please use full names and make sure the spelling is exactly as you want it to appear on the birth certificate for your baby, the other parent, and your own name. The first time you order a certified copy of the birth certificate, please confirm that the information, including spelling, is correct.

Collecting Information Required by Federal Law Federal law requires that parents’ social security numbers be collected at the time of birth. This information would be used only for support enforcement purposes and is not included on the birth certificate.

Gathering Medical Information that is Used for Public Health There are many questions on the ‘Certificate of Live Birth’ form (filed by the hospital) that will not appear on the birth certificate of your child. Your information is combined with records of other births in Oregon. The combined information tells us which health services were used, what problems women are having during their pregnancies, and what health outcomes occur in Oregon. This information helps agencies decide what services to offer and the levels of need among groups of women. This is why we ask for information about race, ethnicity, education, number of prenatal visits, and many other detailed questions. Although not used on the birth certificate of your baby, this information is used to improve the health of women and babies in the future. The information is used to improve programs and to continue funding successful programs. Oregon law requires collection of this information. This information might also be used to identify infants who need services due to a medical condition. If so, state or county public health staff might contact you to refer your child to the needed service. Infrequently, contact information (name, address, and telephone number) might be released for public health research. Public health researchers have the goal of understanding medical or services needs, and to help communities plan to meet those needs. Any research of this type has strict requirements for contacting people and for telling people of their rights under the project, including the right to refuse to participate. Please answer every question to the best of your knowledge. Each question has a purpose. Congratulations on Your Baby and Thank You for Your Help.


Parent worksheet for birth certificate CHILD Child’s legal name as you want it to appear on his or her birth certificate _______________________ ___________________ _____________________ _____________________ ______ First


Other middle


Date of birth Month ____________ Day ______ Year ________





BIRTH MOTHER Your current legal name _______________________ ___________________ _____________________ _____________________ ______ First


Other middle



Your legal name on your birth certificate. Do not report the name from a legal name change (i.e., court-ordered name change, adoption, etc.) unless your birth certificate was amended. Same as current legal name _______________________ ___________________ _____________________ _____________________ ______ First


Other middle



Your date of birth Month ____________ Day ______ Year ________ Your place of birth ____________________________ _______________________________ US State or Canadian province


BIRTH MOTHER’S ADDRESS AND TELEPHONE NUMBER Residence address _____________________________________________________________ Street address including apartment or unit number

_________________________ __________________________ ____________________ ________ City

Inside city limits?







Mailing address Same as residence address If different ____________________________________________________ Street address or PO Box, including apartment or unit number

___________________________ _____________________ ___________ City


Primary telephone number BIRTH MOTHER’S ATTRIBUTES


Secondary telephone number

Education: What is the highest level of education you have completed? th

8 grade or less th th 9 – 12 grade; no diploma High school diploma or GED Some college credit but no degree

Associate’s degree (e.g. AA, AS) Bachelor’s degree (e.g. BA, BS, AB) Master’s degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Doctorate (e.g. PhD, EdD) or Professional degree (MD, DDS, DVM, JD)

Ethnicity: Are you of Hispanic origin? (e.g. Cuban, Mexican, Puerto Rican, etc.) Check one or more; do not leave blank. No, not Spanish/Hispanic/Latina Yes, Mexican, Mexican-American, Chicana Yes, Puerto Rican

Yes, Cuban Yes, other Spanish/Hispanic/Latina (specify) ________________________________________


Race: What is your race(s)? Please check one or more races to indicate what you consider yourself to be. American Indian or Alaskan Native (specify tribe(s)) ____________________________ ____________________________ Asian Indian Black or African American Chinese Filipino Guamanian or Chamorro Japanese Korean Native Hawaiian_______________________________

Samoan Vietnamese White Other Asian (specify) ________________________________ ________________________________ Other Pacific Islander (specify) _________________________________ _________________________________ Other (specify) ________________________________

BIRTH MOTHER’S HEALTH Did you get WIC food for yourself during this pregnancy? Your height ______ feet ______ inches



Your weight before you became pregnant _______ Current weight _______

Cigarette smoking before/during pregnancy 3 months before pregnancy # ______ Cigarettes/day Packs/day st 1 3 months of pregnancy # ______ Cigarettes/day Packs/day nd Didn’t smoke 2 3 months of pregnanc y # ______ Cigarettes/day Packs/day rd 3 3 months of pregnancy # ______ Cigarettes/day Packs/day Did you drink alcohol during this pregnancy?



If yes, average number of drinks per week? ______

LEGAL RELATIONSHIP OF PARENTS Were you married (did you have a legal husband) at conception, at birth, any time between or within 300 days prior to birth? Yes No


If yes, please complete the following Father/Second Parent section with information about your husband. If not married, are you in an Oregon Registered Domestic Partnership?



If yes, please complete the Father/Second Parent section with your partner’s information. If you were married or in an Oregon Registered Domestic Partnership at any of the times above, only your husband or partner can be listed as the legal parent of your child without a court or administrative order. If not married or not in an Oregon Registered Domestic Partnership, will you and the father sign a paternity acknowledgment to establish legal paternity at this time? Yes No If a paternity acknowledgment will be signed, please complete the Father/Second Parent section.


FATHER/SECOND PARENT LEGAL INFORMATION Current legal name _______________________ ___________________ _____________________ _____________________ ______ First


Other middle



Date of birth Month ____________ Day ______ Year ________ Place of birth ____________________________ _______________________________ US State or Canadian province


FATHER/SECOND PARENT ATTRIBUTES – Please provide the following information about the Father/Second Parent. Education: What is the highest level of education the father/second parent has completed? 8th grade or less 9th – 12th grade; no diploma High school diploma or GED Some college credit but no degree

Associate’s degree (e.g. AA, AS) Bachelor’s degree (e.g. BA, BS, AB) Master’s degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Doctorate (e.g. PhD, EdD) or Professional degree (MD, DDS, DVM, JD)

Ethnicity: Is father/second parent of Hispanic origin? (e.g. Cuban, Mexican, Puerto Rican, etc.) Check one or more; do not leave blank. No, not Spanish/Hispanic/Latina Yes, Cuban Yes, Mexican, Mexican-American, Chicana Yes, other Spanish/Hispanic/Latina (specify) Yes, Puerto Rican ________________________________________ FATHER/SECOND PARENT ATTRIBUTES continued Race: What is the father/second parent’s race(s)? Please check one or more races to indicate what the father/second parent considers themselves to be. American Indian or Alaskan Native (specify tribe(s)) ____________________________ ____________________________ Asian Indian Black or African American Chinese Filipino Guamanian or Chamorro Japanese Korean Native Hawaiian ________________________________

Samoan Vietnamese White Other Asian (specify) ________________________________ ________________________________ Other Pacific Islander (specify) _________________________________ _________________________________ Other (specify) ________________________________


PRENATAL Principal payment for delivery Medicaid/OHP Private insurance Self-pay Date of your last menses

Indian Health Services Champus/Tricare Other government

Month ______ Day ______ Year ______

Prenatal Care No prenatal care First prenatal visit ______ ______ ______ Month

Other ___________________________


Last prenatal visit ______ ______ ______ Total prenatal visits _____





Previous live births Currently living None Number _______ Previous live births now dead None Number ________ Date last live birth Month ______ Year _______ Other pregnancy outcomes None Number _____ Date of last other outcome Month ______ Year ______


Birth Mother


Second Parent

Other (specify relationship) _________________________________ If other than parent, ____________________ _____________________ First name

Middle name

______________________ ______

Last name


I certify that the information provided on this form for the purpose of registering the birth is correct to the best of my knowledge. __________________________________________________ Date signed: _________________ Informant’s signature


Request that Social Security Number to be issued

Child’s name _____________________ _____________________ __________________ ________ First




Date of birth (Month – Day – Year) _________________________ Do you want a Social Security number issued to your child? Yes


Signature ___________________________________

Date signed _______________

A Social Security number is required to claim the child on the parents’ income tax return, to qualify for many state and federal programs, and other benefits. When a Social Security number is requested, federal law permits the Social Security Administration to forward the information of the parents and the child to the Internal Revenue Service for the purpose of determining income tax credits. In addition, federal law requires the collection of parents’ Social Security numbers at the time of the child’s birth for child support purposes. This information will be provided to the Division of Child Support, Oregon Department of Justice. Birth Mother’s name _____________________ _____________________ __________________ ________ First




Social Security number _______________________ None

Father/Second Parent’s name (if listed on birth certificate) _____________________ _____________________ __________________ ________ First




Social Security number _______________________ None

This form and only this form may be made a part of the permanent medical record to document the request that a Social Security number be issued.


Exhibit B



DIRECTIVE NO. 15 RACE AND ETHNIC STANDARDS FOR FEDERAL STATISTICS AND ADMINISTRATIVE REPORTING (as adopted on May 12, 1977) This Directive provides standard classifications for record keeping, collection, and presentation of data on race and ethnicity in Federal program administrative reporting and statistical activities. These classifications should not be interpreted as being scientific or anthropological in nature, nor should they be viewed as determinants of eligibility for participation in any Federal program. They have been developed in response to needs expressed by both the executive branch and the Congress to provide for the collection and use of compatible, nonduplicated, exchangeable racial and ethnic data by Federal agencies.

1. Definitions The basic racial and ethnic categories for Federal statistics and program administrative reporting are defined as follows: a. American Indian or Alaskan Native. A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition. b. Asian or Pacific Islander. A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa. c. Black. A person having origins in any of the black racial groups of Africa. d. Hispanic. A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race. e. White. A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

2. Utilization for Record keeping and Reporting To provide flexibility, it is preferable to collect data on race and ethnicity separately. If separate race and ethnic categories are used, the minimum designations are: a. Race: -- American Indian or Alaskan Native --Asian or Pacific Islander --Black --White b. Ethnicity: --Hispanic origin --Not of Hispanic origin

When race and ethnicity are collected separately, the number of White and Black persons who are Hispanic must be identifiable, and capable of being reported in that category. If a combined format is used to collect racial and ethnic data, the minimum acceptable categories are: --American Indian or Alaskan Native --Asian or Pacific Islander 19

--Black, not of Hispanic origin --Hispanic --White, not of Hispanic origin.

The category which most closely reflects the individual's recognition in his community should be used for purposes of reporting on persons who are of mixed racial and/or ethnic origins. In no case should the provisions of this Directive be construed to limit the collection of data to the categories described above. However, any reporting required which uses more detail shall be organized in such a way that the additional categories can be aggregated into these basic racial/ethnic categories. The minimum standard collection categories shall be utilized for reporting as follows: a. Civil rights compliance reporting. The categories specified above will be used by all agencies in either the separate or combined format for civil rights compliance reporting and equal employment reporting for both the public and private sectors and for all levels of government. Any variation requiring less detailed data or data which cannot be aggregated into the basic categories will have to be specifically approved by the Office of Management and Budget (OMB) for executive agencies. More detailed reporting which can be aggregated to the basic categories may be used at the agencies' discretion. b. General program administrative and grant reporting. Whenever an agency subject to this Directive issues new or revised administrative reporting or record keeping requirements which include racial or ethnic data, the agency will use the race/ethnic categories described above. A variance can be specifically requested from OMB, but such a variance will be granted only if the agency can demonstrate that it is not reasonable for the primary reporter to determine the racial or ethnic background in terms of the specified categories, and that such determination is not critical to the administration of the program in question, or if the specific program is directed to only one or a limited number of race/ethnic groups, e.g., Indian tribal activities. c. Statistical reporting. The categories described in this Directive will be used at a minimum for federally sponsored statistical data collection where race and/or ethnicity is required, except when: the collection involves a sample of such size that the data on the smaller categories would be unreliable, or when the collection effort focuses on a specific racial or ethnic group. A repetitive survey shall be deemed to have an adequate sample size if the racial and ethnic data can be reliably aggregated on a biennial basis. Any other variation will have to be specifically authorized by OMB through the reports clearance process. In those cases where the data collection is not subject to the reports clearance process, a direct request for a variance should be made to OMB.

3. Effective Date The provisions of this Directive are effective immediately for all new and revised record keeping or reporting requirements containing racial and/or ethnic information. All existing record keeping or reporting requirements shall be made consistent with this Directive at the time they are submitted for extension, or not later than January 1, 1980. 4. Presentation of Race/Ethnic Data Displays of racial and ethnic compliance and statistical data will use the category designations listed above. The designation "nonwhite" is not acceptable for use in the presentation of Federal Government data. It is not to be used in any publication of compliance or statistical data or in the text of any compliance or statistical report. In cases where the above designations are considered inappropriate for presentation of statistical data on particular programs or for particular regional areas, the sponsoring agency may use: 20

(1) The designations "Black and Other Races" or "All Other Races," as collective descriptions of minority races when the most summary distinction between the majority and minority races is appropriate; (2) The designations "White," "Black,"and "All Other Races" when the distinction among the majority race, the principal minority race and other races is appropriate; or (3) The designation of a particular minority race or races, and the inclusion of "Whites" with "All Other Races," if such a collective description is appropriate. In displaying detailed information which represents a combination of race and ethnicity, the description of the data being displayed must clearly indicate that both bases of classification are being used. When the primary focus of a statistical report is on two or more specific identifiable groups in the population, one or more of which is racial or ethnic, it is acceptable to display data for each of the particular groups separately and to describe data relating to the remainder of the population by an appropriate collective description. Source: Excerpt from accessed on August 8, 2005.


Exhibit C

Live Birth Record Template



Exhibit D

Vaccine Exemption Template


The First Amendment of the United States Constitution guarantees freedom of religion. The test in determining whether a belief constitutes a “religious belief” sufficient to qualify for the religious exemption from immunizations, is whether the adherents “beliefs and faiths occupy a place in their lives parallel to that filled by the orthodox belief in God held by others’ or any other “sincere religious beliefs which are based on a power or being. Or upon a faith to which all else is subordinate or upon which all else ultimately dependent.” U.S. Vs. Seeger, 380 U.S. 163 (1965), Sherr and Levy vs Northport EastNorthport Union Free School District, 672 F. Supp. 81, (E.D.N.Y 1987) The right to claim exemption from immunization based on religious belief is available to all persons who hold religious beliefs against immunization regardless of what any state statute may say regarding the necessity for membership in any particular religious group or church. The first amendment to the U.S. Constitution prohibits states from discriminating between people based on their religious beliefs. O there is any state law that allows for exemption based on religious beliefs, it is available to all those people who hold religious beliefs against immunization even if their beliefs are personal and unique to them alone. New York is a state that allows for a wide religious exemptions; NY only requires notification or parental statement:

NY CLS Pub. Health § 2164 (9) This section shall not apply to children whose parent, parents, or guardian hold genuine and sincere religious beliefs which are contrary to the practices herein required, and no certificate shall be required as a prerequisite to such children being admitted or received into school or attending school. Procedures to secure this document  This document must be notarized 

This document should be authenticated in the County and in the State where you and your child will be contracting

This document should be authenticated and apostilled with the State that you and your child will be conducting the business of “education”

This document should be recorded with the Recorder of Deeds in the county where you and your child will be contracting


Vaccine Exemption Template Church or Temple(Optional) Jurisprudence Division (Optional) Address Line 1 Address Line 2 City, State Zip State of_______________________ _______________________County 1. I am the parent of child 2. I hereby affirm that I subscribe to Aboriginal Islam a belief in relation to a Supreme Being, Reason, and Nature involving primary duties superior to those arising from any human or human being relation to the U.S., U.S.A. or any jurisdiction thereof. 3. I further affirm that my belief Is honest, sincere, truthful, meaningful and occupies a place in our life parallel to that filled by my orthodox belief in the Supreme Laws of Nature. 4. This belief is not merely a political. Sociological, or philosophical view of a personal moral code. 5. This inner and overstanding, belief and my status as an Aboriginal Sovereign Moor of the Murakush Empire foreign to the U.S. and any State within the Union of States, Grand Sheikess of the Moorish Science Temple of America (dba Murakush Temple of Science), gives my child, attribute of child, exemption from any required testing medical or otherwise and Immunization Shots et al. _________________________________Place your Signature here SWORN TO AND SUBSCRIBED before me, a registered Notary Public, this _________day of _________. 20__ ________________________________ Notary Public


Birth Certificate Workbook  

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