Mandatory 15 Pages must be returned.          HireLyrics Administrative Services U.S. Citizens Public Docket Database     ...
Mandatory 15 Pages must be returned.HireLyrics Trial Prep Evidence Binder:        Legal Administrative Assistant Summarize...
Mandatory 15 Pages must be returned.                                           Certified Service Distribution of Form COL ...
Mandatory 15 Pages must be returned.HireLyrics FORM:            Response to Client Work Order Request Query(assesses costs...
Mandatory 15 Pages must be returned.                                     FEDERAL CRIME VICTIM DISCLOSUREChild’s Full Name ...
Mandatory 15 Pages must be returned.Form   COL Violation Warning Denial of Rights Under Color of LawViolation Warning—18 U...
Mandatory 15 Pages must be returned.                 AUTHORIZATION FOR RELEASE OF INFORMATIONMedical Records, Department o...
Mandatory 15 Pages must be returned.          REVOCATION OF AUTHORIZATION FOR RELEASE OF INFORMATIONNOTICE IS HEREBY GIVEN...
Mandatory 15 Pages must be returned.          HireLyrics Administrative Services U.S. Citizens Public Docket Database     ...
Mandatory 15 Pages must be returned.Child Support, Student Loan, Welfare, Food Stamp Lien or IRS or State Tax Penalties Li...
Mandatory 15 Pages must be returned.AGREEMENT IS MADE THIS DAY BETWEENI, (full name including middle name or initial) ____...
Mandatory 15 Pages must be returned.with U.S. states statutes and Internal Revenue Service Business Registration and Tax R...
Mandatory 15 Pages must be returned.SPECIAL PROSECUTORS, INTELLIGENCE OFFERS, LAW ENFORCEMENT, PRIVATE INVESTIGATORS,SECUR...
Mandatory 15 Pages must be returned.OF A CRIME VICTIM WHO IS UNDER 18 YEARS OF AGE, INCOMPETENT,INCAPACITATED, OR DECEASED...
Mandatory 15 Pages must be returned.business method, HireLyrics Administrative Services, whose practice models demonstrate...
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012212 Retain Roxanne Grinage Legal Administrative Assistant HireLyrics Pro Se Document Production Option 1 Federal Crime Victim Voters created by Malpractice Official Corruption Fraud Civil Rights

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012212 Retain Roxanne Grinage Legal Administrative Assistant HireLyrics Pro Se Document Production Option 1 Federal Crime Victim Voters created by Malpractice Official Corruption Fraud Civil Rights

  1. 1. Mandatory 15 Pages must be returned. HireLyrics Administrative Services U.S. Citizens Public Docket Database Form of Employment Agreement Retain Roxanne Grinage Legal Administrative Assistant Project Manager Option 1 Standard Pro Se Document Production Claims Forms and Certified Service Notice. Effective/Mandatory 01/22/12 Roxanne Grinage HireLyrics Administrative Services U.S. Citizens Public Docket Database PO Box 22225 Philadelphia Pa 19136 267-444-0594 Fax 215-405-2939 www.HireLyrics.org www.twitter.com/HireLyrics www.facebook.com/Roxanne.Grinage www.Youtube.com/HireLyrics www.Youtube.com/WhatIsThereLeftToDo www.Youtube.com/RoxanneGrinage www.ireport.cnn.com/people/HireLyrics “HireLyrics™ JOBS CREATION 2012 Law Enforcement Are Working Class People Too!”© FEDERAL CRIME VICTIM VOTERS Created By Official Corruption Fraud Civil Rights Crime American Working Class Students Impoverished Families & Business Owners HireLyrics™ Scope of Services OPTION 1: PRO SE DOCUMENT PRODUCTIONThese standard services are a preview of Jobs Creation 2012 HireLyrics is in the process of applying for grant funding for so that financiallydevastated American Federal Crime Victims verified by standard access to claims intake assessment and litigation referral may receive ProSe Document Production and Claims Forms Preparation free or at substantially subsidized cost while community enrichment jobs arecreated.Revised 1/22/12: Cost is $1,200.00 retain full time Legal Administrative Assistant Project Manager professional services for twelve calendarweek period. Minimum deposit $600.00, payment arrangements available installments $200.00 per month for period of twelve months. Seefull 46 pages Terms and Conditions Confidentiality Privacy Termination for Cause Conflict of Interest Disclosures and Disclaimers includingCompliance with all Federal State Internal Revenue and States Departments of Taxation and Revenue Congressional Acts, etc which allHireLyrics Standard Access to Standard Services to raise quality of life for a previously un-accommodated population of federal crime victimscreated by official corruption fraud civil rights crimes are in compliance with.HireLyrics Claims Intake Assessment Performed by a Legal Administrative Assistant: Evidence Gathering Depositions and Expert Witness TestimonyHireLyrics Litigation Referral: Legal Administrative Assistant Verification Report: Docket Analysis; Identify Conflict of Interest; Measure Individual AccountabilityMerits of Claim Contingent Liabilities Components: Work Ethic, Compliance, Negligence, RecordsAssessed; verified evidence indicated Calls Mismanagement, Employee Misconduct, Malpractice; Embezzlement orfor Class Action, Special Prosecutor or Fraudulent Billing; discern whether bogus warrants, whistleblowerDefense, Private Investigator, Forensics, retaliation, false arrest, nepotism or judicial tyranny.Credentialed Expert Witnesses or otherLegal Industry Support Service including Package and submit due diligence as trial prep evidence modules whichtranscriptionists researchers paralegals, responsibly record respectfully report degrees of individual accountabilitytechnology, law or business school students. for Official Corruption Fraud Civil Rights crimes perpetrated under color of law against American working class student impoverished families and business owners. Page 1 of 15 mandatory returned.
  2. 2. Mandatory 15 Pages must be returned.HireLyrics Trial Prep Evidence Binder: Legal Administrative Assistant Summarized Marked Exhibits Index provided to HireLyrics Client on Data Disc or Flash Drive and, if authorized by Federal Crime Victim Pro Se Claimant, active links posted to HireLyrics Administrative Services managed case study page prototype demonstration of U.S. Citizens Public Docket Database on the internet at www.HireLyrics.org.U.S.D.C. Pro Se Forms Compliant Federal HireLyrics Legal Administrative Assistant Drafts Affidavit of FactsCivil Lawsuit Complaint compiled from evidence provided by Federal Crime Victim Claimant; prepares U.S. District Court official package of pro se Federal Lawsuit Complaint form, and if asked by HireLyrics Client, gathers the information necessary and completes U.S.D.C. pro se forms package compliant Petition Informa Pauperis (Poverty Affidavit; Indigent Litigant) asking U.S. District Court for permission to waive Filing Fee. The Pro Se Claimant (HireLyrics Client) must sign and file with the Court by Certified Mail or Hand Delivery on their own behalf. HireLyrics Legal Administrative Assistants are not attorneys are not enrolled to practice before the IRS and do not represent any person in any court or claims process.If verified evidence indicates: Presidential Executive Officers, U.S. Department of Justice, Appropriate U.S. Senate Committees, U.S. Courts Administration; State Lawmakers,HireLyrics Certified Service Distribution Child Abuse Registry, Child Support Enforcement, Licensing andFraud Report Whistleblower Transmittal Disciplinary Review Boards, Internal Revenue Service Office ofLaw Enforcement Investigation and Audit Professional Responsibility (IRS OPR); U.S. government AccountabilityRequest Office (GAO) and others as verified evidence indicates and lawful reporting opportunities become available.If verified evidence indicates: In an effort to send a clear message that HireLyrics will not allow the quality of life enhancing results of a standard access mechanism to beAppropriate Referrals to U.S. Department of hindered by misuse, HireLyrics will promptly report all facts and evidenceJustice Programs (OJP Victims of Crime): discerned during claims intake assessment; due diligence, trial prep,Domestic Violence Elderly Abuse and research and discovery including those challenges and crimes for whichMistreatment Identity Theft or Theft by there is help or criminal justice intervention by way of appropriateDeception Schemes. referral. Example: If a Federal Crime Victim’s claims of official corruption are verified and the claimant is observed to need help with addiction, vocational rehab, arrest recidivism intervention or penal action is necessary to intervene in a discovered domestic violence or elder abuse, identity theft or scams of defenseless Americans; HireLyrics will move swiftly decisively lawfully and without notice to cause appropriate reports referrals and notices to appropriate law enforcement and funded neighborhood innovation programs.If verified evidence indicates: HireLyrics Certified Service Notice to Federal State County Employers of evidence verified Employee(s) or Professional Practitioner Misconduct,HireLyrics Certified Service Notice to Bribery, Coercion, Intimidation, Extortion, Nepotism, Cover Up CensorshipFederal State County Employers. Rerouting Destruction of Evidence, court filings, Falsification of Records Fraud Embezzlement Kidnap For Profit.If verified evidence indicates: U.S. Department of Justice Form 95 Claim For Damages or Wrongful Death Caused by a Federal Agency.If verified evidence indicates: U.S. Department of Justice Office of Inspector General (OIG) Fraud Waste Abuse Misconduct Report.If verified evidence indicates: Certified Service Form COL Violation Warning Denial of Rights Under Color of Law Violation Warning—18 U.S.C. §242; 18 U.S.C. §245; 42 U.S.C. §1983. “I certify that the forgoing information stated here is true and correct. Legal Notice and Warning - Federal law provides that it is a crime to violate the Rights of a citizen under the color-of-law. You can be arrested for this crime and you can also be held personally liable for civil damages.” Page 2 of 15 mandatory returned.
  3. 3. Mandatory 15 Pages must be returned. Certified Service Distribution of Form COL Violation Warning Denial of Rights Under Color of Law Violation Warning—18 U.S.C. §242; 18 U.S.C. §245; 42 U.S.C. §1983 is always publicly posted to HireLyrics Administrative Services managed case study pages within prototype demonstration of U.S. Citizens (controlled) Public Docket Database.If verified evidence indicates: Dept of Justice Executive Office For Immigration Review Alien’s Change of Address Form Board of Immigration AppealsIf verified evidence indicates: Dept of Justice Executive Office For Immigration Review Immigration Practitioner ComplaintIf verified evidence indicates: Dept of Justice Executive Office For Immigration Review Application for Cancellation of Removal and Adjustment of Status for Certain Nonpermanent Residents PHOTOCOPY PROOF OF IDENTITY DOCUMENTS ONTO SEPARATE PAGE (MANDATORY RETURNED)  STATE ISSUED PHOTO I.D. CARD OR DRIVER’S LICENSE.  STUDENT I.D. CARD  A clear readable copy of all SOCIAL SECURITY CARDS ever issued to you.  BIRTH CERTIFICATE.  VOTER REGISTRATION CARD OR CHECK HERE IF YOU ARE NOT REGISTERED TO VOTE ______  MEDICAL INSURANCE or LABOR UNION MEMBERSHIP CARDS. Roxanne Grinage HireLyrics Administrative Services U.S. Citizens Public Docket Database PO Box 22225 Philadelphia Pa 19136 267-444-0594 Fax 215-405-2939 www.twitter.com/HireLyrics www.facebook.com/Roxanne.Grinage www.Youtube.com/HireLyrics www.Youtube.com/WhatIsThereLeftToDo www.Youtube.com/RoxanneGrinage Page 3 of 15 mandatory returned.
  4. 4. Mandatory 15 Pages must be returned.HireLyrics FORM: Response to Client Work Order Request Query(assesses costs billing revenues and contingent liabilities relative to business development rationale and is tobe automatically triggered when a HireLyrics Pro Se Document Production Client requests Project Task orDocument Production which is not available in HireLyrics Option 1 Standard Complaint and Dept of JusticeClaims Forms Package)Definition: Queries are the primary mechanism for retrieving information from a database and consist ofquestions presented to the database in a predefined format. Many database management systems use theStructured Query Language (SQL) standard query format. Roxanne Grinage Write the Title of the document you want HireLyrics to produce for you. If you do not know the title of the document write the objective – what you want to accomplish by HireLyrics Administrative Services filing the document into a Court of Law or other Claims process. U.S. Citizens Public Docket _____________________________________________________________ Federal Crime Victim Voters _____________________________________________________________ Safe Haven DHS Abused Runaways Write where HireLyrics can find on the internet the work you already did. Write the url Grinage Family Private Investigation of the domain or webpage. If not on internet write the names of Case CaptionsRescue 06/08/10 Parent Public Mob Assault Courts and Docket Numbers, Case Numbers that you are faxing or sending to Children of Lorraine Grinage Ezekiel Z HireLyrics in the mail. Brown and Arriyel R Brown _____________________________________________________________ PO Box 22225 Philadelphia PA 19136 _____________________________________________________________ Tel. (267) 444-0594 Fax. (215) 405-2939 1. Indicate by checking Yes or No whether you authorize HireLyrics to perform the www.HireLyrics.org following Administrative Marketing Careers eCommerce (fundraising) records requests www.HireLyrics.com via domains and log ins controlled exclusively by Roxanne Grinage and not the www.BlogTalkRadio.com/Born-To-Serve HireLyrics client relative to what we learn, promote, sell publish advertise on your www.Twitter.com/HireLyrics behalf as we produce your projects tasks research and documents: www.Facebook.com/Roxanne.Grinage www.ireport.cnn.com/people/HireLyrics Can HireLyrics order records and makes inquiries to people, witnesses, hospitals, www.YouTube.com/HireLyrics coroners, department of justice, lawyers, IRS, State Treasurers about unclaimedwww.YouTube.com/WhatIsThereLeftToDo property, States Departments of Taxation and Revenue about penalties liens www.YouTube.com/Roxanne.Grinage garnishments etc. Can Roxanne Grinage compose and manage correspondence and telephone calls in the professional capacity as your hired legal executive assistant? _____Yes or _____No 2. Can HireLyrics publish a case study page and rigorously defend DMCA, reporter and citizens journalism right to do so; U.S. Citizens (controlled) Public Docket Database public post incident reports: the verified findings of facts matter status and certified service distribution of true and correct copies HireLyrics has provided you with originals to file by certified mail return receipt requested as a pro se litigant? ____Yes or ____No 3. Can HireLyrics include your verified merits of claim amongst various fundraising initiatives managed by HireLyrics and HireLyrics report to you only those fund received expressly marked by the donor to be used for your particular litigation marketing careers ecommerce ventures managed by HireLyrics on your behalf? _____ Yes _____ No 4. Will you talk to show up on talk radio or internet tv or other media suggested by Roxanne Grinage, Will you participate in three way calls with project team members that HireLyrics puts together and asks for their help without hindering our competitiveness effectiveness with a bunch of warnings hesitation and paranoia? Are you able to understand that if HireLyrics accepts you as a disadvantaged creator or federal crime victim claimant client that your accountability is to HireLyrics within the terms of the contract we agree on and HireLyrics is only accountable to you and no one else within the terms of the contract terms we agree on and once HireLyrics has pitched to you respectful suggestions career paths growing we will not spend any more time convincing you to trust HireLyrics growing constituencies of a tragically far too large claimant constituency who is competitively focused on galvanizing grassroots Federal Crime Victim Voter Clout? _____Yes or _____No. Page 4 of 15 mandatory returned.
  5. 5. Mandatory 15 Pages must be returned. FEDERAL CRIME VICTIM DISCLOSUREChild’s Full Name Date of Birth given to me by God Child’s Date of Birth and last known SSN You do not have to fill this in if you are not a CPS Corruption in Government kidnap for profit victim.Child’s Full Name Date of Birth given to me by God Child’s Date of Birth and last known SSNChild’s Full Name Date of Birth given to me by God Child’s Date of Birth and last known SSNChild’s Full Name Date of Birth given to me by God Child’s Date of Birth and last known SSNFor those claimants who died.Estate of ____________________________________________________________________________(Date of Birth and Date of Death) Send copy of Death Certificate and Names of Hospitals and Coroners.Estate of ____________________________________________________________________________(Date of Birth and Date of Death) Send copy of Death Certificate and Names of Hospitals and Coroners.I certify I am a Federal Crime Victim* as defined by United States Department of Justice as set forth in 18 U.S.C. §3771: * ACCORDING TO THE ACT, A VICTIM IS “A PERSON DIRECTLY AND PROXIMATELY HARMED AS ARESULT OF THE COMMISSION OF A FEDERAL OFFENSE OR AN OFFENSE IN THE DISTRICT OF COLUMBIA. INTHE CASE OF A CRIME VICTIM WHO IS UNDER 18 YEARS OF AGE, INCOMPETENT, INCAPACITATED, ORDECEASED, THE LEGAL GUARDIANS OF THE CRIME VICTIM OR REPRESENTATIVES OF THE CRIME VICTIM’SESTATE, FAMILY MEMBERS, OR ANY OTHER PERSONS APPOINTED SUITABLE BY THE COURT, MAY ASSUMETHE CRIME VICTIM’S RIGHT UNDER THIS CHAPTER, BUT IN NO EVENT SHALL THE DEFENDANT BE NAMEDAS SUCH GUARDIAN OR REPRESENTATIVE.”I, certify that I have acted lawfully responsibly and respectfully throughout all corruption poisoned processes andvenues and continue to act lawfully as a proud resident of United States, committed to leveraging individualaccountability forbidding abuse of immunity language in 1983 Civil Rights Act which is being used by criminallybehaving official corruption fraud civil rights assailants to perpetrate felony crimes upon working class student andimpoverished families to perpetrate a Child Slaughter U.S. Economy Fraud Court and Education Reform State ofEmergency in my state and our nation.I, certify I have caused the foregoing to be transmitted by electronic mail or facsimile or postage prepaid first classmail or by certified mail return receipt requested or by priority mail by authorizing Roxanne Grinage, HireLyricsAdministrative Services U.S. Citizens (controlled) Public Docket Database or formation pending Federal CrimeVictim Voters Safe Haven DHS Abused Runaways as indicated on various Certified Service Distribution Listsmanaged and published by HireLyrics Administrative Services in satisfaction of my state’s Rules for Service, CivilRules of Procedure and as Crime Victim Compensation Claimant, Recovery Act Fraud and Waste WhistleblowerTransmittal, President Executive Office, United States Attorney General and Special Prosecutors, LegislativeCommittees, Funding Source Decision Makers, Intervention Investigations and Audit Requests.I am a resident of ______________________(state) and lawful guardian of above named real flesh and blood naturalpersons for whom god saw fit to bless me with and in whom I have a greater vested interest in the heritage healtheducation religious freedoms whereabouts future U.S. economy enriching careers contributions than does anycorporate entity, state agency employees and contractors or other professional practitioner._____________________________________________________ Date signed:___________________________Signature Federal Crime Victim Witness_____________________________________________________Print Name Federal Crime Victim Witness Page 5 of 15 mandatory returned.
  6. 6. Mandatory 15 Pages must be returned.Form COL Violation Warning Denial of Rights Under Color of LawViolation Warning—18 U.S.C. §242; 18 U.S.C. §245; 42 U.S.C. §1983I certify that the forgoing information stated here is true and correct.Legal Notice and Warning - Federal law provides that it is a crime to violate the Rights of acitizen under the color-of-law. You can be arrested for this crime and you can also be heldpersonally liable for civil damages.Attempting to cause a person to do something by telling that person that such action is required by law,when it is not required by law, may be a felony.18 USC §242 provides that whoever, under color of any law, statute, ordinance, regulation, or custom,willfully subjects any person in any State, Territory, Commonwealth, Possession, or District to thedeprivation of any rights, privileges, or immunities secured or protected by the Constitution or laws of theUnited States shall be fined under this title or imprisoned not more than one year, or both.18 USC §245 provided that Whoever, whether or not acting under color of law, intimidates or interfereswith any person from participating in or enjoying any benefit, service, privilege, program, facility, or activityprovided or administered by the United States; [or] applying for or enjoying employment, or any perquisitethereof, by any agency of the United States; shall be fined under this title, or imprisoned not more thanone year, or both.42 USC §1983 provides that every person who, under color of any statute, ordinance, regulation, custom,or usage, of any State or Territory or the District of Columbia, subjects, or causes to be subjected, anycitizen of the United States or other person within the jurisdiction thereof to the deprivation of any rights,privileges, or immunities secured by the Constitution and laws, shall be liable to the party injured in anaction at law, suit in equity, or other proper proceeding for redress.Warning, you may be in violation of Federal Law and persisting with your demand may lead to your arrestand/or civil damages! Also understand that the law provides that you can be held personally responsibleand liable, as well as your company or agency. You are advised to CEASE AND DESIST withyour demand and to seek personal legal counsel if you do not understand the law.Notice of Service: I CERTIFY I AUTHORIZED HIRELYRICS ADMINISTRATIVE SERVICES LEGAL ADMINISTRATIVEASSISTANTS MANAGED BY ROXANNE GRINAGE TO CERTIFY SERVICE OF THIS NOTICE IN ACCORDANCE WITHEVIDENCE GATHERED DEPOSITIONS AND EXPERT WITNESS TESTIMONY VERIFIED._________________________________________________________________________________Sign and Print Your Name with Full Address including city, state and postal zip code [SIGN AND PUT YOUR ADDRESS ABOVE AND DO NOT WRITE BELOW THIS LINE]I, certify that I, Roxanne Grinage, HireLyrics Administrative Services, U.S. Citizens Public Docket Databasecaused this Form COL Legal Notice and Warning Violation of Rights Under Color of Law to be served byelectronic, facsimile, or first class mail postage prepaid to attached certified service distribution namedrecipients at their official addresses of public record. Returned Affidavit Proof of Service is Null and Void if notpresented with attached Roxanne Grinage HireLyrics Administrative Service verified Certified ServiceDistribution List. Date:Roxanne Grinage HireLyrics Administrative Services U.S. Citizens Public Docket Database Page 6 of 15 mandatory returned.
  7. 7. Mandatory 15 Pages must be returned. AUTHORIZATION FOR RELEASE OF INFORMATIONMedical Records, Department of Health and Human Services, All Registries, Hospital, Healthcare Providers, Social Worker, CaseWorkers, Police Reports, Detective Case Notes, Investigations and Findings, Attorney Client Files about me and or my family who isshown to be injured by way of Official Corruption Fraud Civil Rights Violations.Name:___________________________________________________________________Telephone Number for Verification: ____________________________________________SSN:___________________________ DOB:____________ Email: ______________________Other Names Under Which Records Might Be Filed:______________________________________________________________________________Person Court Agency Organization or Professional Practitioner Releasing the Information:X Department of Health and Human Services, Commissioner’s office _________________________________________________________________Name and AddressX Child Abuse Registry __ Other Registry __________________________X DHS or DHSS CPS or CWS OCS CYS contractor residential facility name and address ___________________________________________________________X Hospital or Physician Medical Records maintained by Records Custodian(s) at _____________________________________________________________ (Healthcare provider name and address) _____________________________________________________________ (Healthcare provider name and address)X CPS DHS OCS CYS CWS Social Workers Case Workers Foster Adoption Evaluator Employees or Contractors known to have records which impact litigation, investigations and audits concerning personal injuries suffered by my family. _____________________________________________________________________________ Name and Address of Office they work(ed) in at the time records were created. ____________________________________________________________________________ Name and Address of Office they work(ed) in at the time records were created.X A Lawyer that represents me or did represent me at one time Name Address Telephone and Fax if known______________________________________________________________________X A Lawyer that represents me or did represent me at one time Name Address Telephone and Fax if known______________________________________________________________________Description of Information to Be Released. (If substance abuse information is to be released from a federally assisted substanceabuse treatment center, than this information must be included in thedescription)._____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________The purpose of the release of this information is: litigation discovery, crime victim compensation claims processesI hereby authorize the use of disclosure of my health care and/or client files and/or other information as described above to,ROXANNE GRINAGE, HIRELRYICS ADMINISTRATIVE SERVICES, PO BOX 22225, PHILADELPHIA, PA, 19136, FAX: 215-405-2939, WEBSITE CONTACT FORMS WWW.HIRELYRICS.ORG. This authorization remains effective for as long as I am aHireLyrics Administrative Services client for whom Roxanne Grinage provides records management among other legal executiveassistant professional services on behalf of me and my family. Signature Printed Name Mailing Address including city state and zip codeSTATE OF ______________ )COUNTY OR DISTRICT )________________________ )Subscribed and sworn to or affirmed before me at (city), (state) On (date).(NOTARY SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. ______________________________________________________________________ My commission expires: Page 7 of 15 mandatory returned.
  8. 8. Mandatory 15 Pages must be returned. REVOCATION OF AUTHORIZATION FOR RELEASE OF INFORMATIONNOTICE IS HEREBY GIVEN THAT THE BELOW CHECKED AGENCY, ORGANIZATION ORPROFESSIONAL PRACTITIONER MAY HAVE BECOME A CONFLICT OF INTEREST PARTY INPENDING OR ONGOING LITIGATION. ANY RELEASES SIGNED BY UNDERSIGNED EITHERWILLINGLY OR UNDER DURESS DURING ANY SPAN OF PERIOD OF TIME ARE HEREBYREVOKED.Name:___________________________________________________________________Telephone Number for Verification: ____________________________________________SSN:___________________________ DOB:____________ Email: ______________________Other Names Under Which Records Might Be Filed:_______________________________________________________________________________________________________Person Court Agency Organization or Professional Practitioner Releasing the Information:X Department of Health and Human Services, Commissioner’s office _________________________________________________________________Name and AddressX Child Abuse Registry __ Other Registry __________________________X DHS or DHSS CPS or CWS OCS CYS contractor residential facility name and address ___________________________________________________________X Hospital or Physician Medical Records maintained by Records Custodian(s) at _____________________________________________________________ (Healthcare provider name and address) _____________________________________________________________ (Healthcare provider name and address)X CPS DHS OCS CYS CWS Social Workers Case Workers Foster Adoption Evaluator Employees or Contractors known to have records which impact litigation, investigations and audits concerning personal injuries suffered by my family. _____________________________________________________________________________ Name and Address of Office they work(ed) in at the time records were created. ____________________________________________________________________________ Name and Address of Office they work(ed) in at the time records were created.X A Lawyer that represents me or did represent me at one time Name Address Telephone and Fax if known______________________________________________________________________X A Lawyer that represents me or did represent me at one time Name Address Telephone and Fax if known______________________________________________________________________Description of Information to Be Released or for which Authorization to Release is Revoked. (If substance abuse information is tobe released from a federally assisted substance abuse treatment center, than this information must be included in thedescription)._____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________THE PURPOSE OF THE REVOCATION OF AUTHORIZATION FOR RELEASE OF INFORMATION: litigation discovery, crimevictim compensation claims processesAll inquiries pertaining to records about my family’s health, heritage, identity, custody, finances, healthcare, etc. are to be directed tothe Legal Administration Services Assistant service we have hired for this purpose. I hereby authorize the use of disclosure of myhealth care and/or client files and/or other information as described above to, ROXANNE GRINAGE, HIRELRYICSADMINISTRATIVE SERVICES, PO BOX 22225, PHILADELPHIA, PA, 19136, FAX: 215-405-2939, EMAIL WEBSITE CONTACTFORMS WWW.HIRELYRICS.ORG. This authorization and/or revocation of authorization for release of information remainseffective for as long as I am a HireLyrics Administrative Services client for whom Roxanne Grinage provides records managementamong other legal executive assistant professional services on behalf of me and my family. Signature Printed Name Mailing Address including city state and zip codeSTATE OF ______________ )COUNTY OR DISTRICT )________________________ )Subscribed and sworn to or affirmed before me at (city), (state) On (date). (NOTARY SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. ______________________________________________________________________ My commission expires: Page 8 of 15 mandatory returned.
  9. 9. Mandatory 15 Pages must be returned. HireLyrics Administrative Services U.S. Citizens Public Docket Database Form of Employment Agreement Retain Roxanne Grinage Legal Administrative Assistant Project Manager Option 1 Standard Pro Se Document Production Claims Forms and Certified Service Notice. Effective/Mandatory 01/22/12 HireLyrics Client Data Sheet PRINT FILL-IN WITH A RESPONSE EVERY SINGLE BLANK MANDATORY RETURNED with Notarized Signed Pages and Photocopies of Identity Documents.HireLyrics Client’s choice of Authorized Representative does not have to provide theinformation on this Client Data Sheet.Write Your Full Name the way it appears on your Birth CertificateWrite your name exactly as it appears on your social security cardWrite your name exactly as it appears on your State Identification Card or DriverLicense.Write your name exactly as it appears on your Student I.D. CardWrite your name exactly as it appears on any “benefit” payments you receivePension Welfare SSI SSD.Write you name exactly as it appears on pay stubs from jobs you worked.Write your name exactly the way it appears on income taxes you filed or on IRSNotices.Write ALSO KNOWN AS VERSIONS OF YOUR NAME.Write your social security number, Bar Attorney ID. PTIN or CAF or Federal State orCriminal Justice or Labor Union Issued Identifying Numbers. PLEASE PROVIDE COPIES WITHIN 72 HOURS OF SUBMITTING THIS FORM OF HIRELYRICS EMPLOYMENT AGREEENT OF THE FOLLOWING IDENTITY DOCUMENTS (Mandatory Returned within 72 Hours)PROOF OF MARRIAGE IF A SPOUSE SIGNS WITH YOU. Okay to show proof living at same address utility bill,joint bank account, affidavits, family reunion rosters and family trees, baptismal records, dated greeting cardsor correspondence addressed to both of you whether you were married in a civil ceremony or not.DIVORCE PETITIONS SEPARATION AGREEMENTS OR DECREES if you don’t want your spouse to show up andclaim rights to your HireLyrics Client Account that you don’t want them to have according to your state’slaws. Your written Affidavit of Truth stating date you and your spouse union is dissolved is acceptabletestimony.A copy of a tax return you filed and/or any recent lien or penalty notices you are receiving from IRS.Eviction or Foreclosure Notices. Page 9 of 15 mandatory returned.
  10. 10. Mandatory 15 Pages must be returned.Child Support, Student Loan, Welfare, Food Stamp Lien or IRS or State Tax Penalties Lien Notices.Notices Letters Petitions Motions or Decisions in Domestic Relations Matters where a relative no matter whatage was taken against your will by a State Court with the participation of a State Agency or one or anycombination of State Agency contractors, Hospital, Nursing Home, Foster Home, Group Home, etc., if you havediscussed with Roxanne Grinage.A List of Hospitals and Doctors where you know records exist that prove your children disabled or elderlyloved ones were over medicated, neglected, abused or otherwise injured by malpractice neglect or recordsmis-management, if you have discussed with Roxanne Grinage. UNCLAIMED PROPERTYHireLyrics researches Unclaimed Property Administrators official website www.missingmoney.org tosee if you or one of your relatives have property being held by a State Treasurer which whenreclaimed will assist with the healing the financial devastation caused to Federal Crime Victimscreated by Official Corruption Fraud Civil Rights crimes.Write your mothers full name and your father’s full name and your grandparents on your mother’sside and your grandparents on your father’s side full name. State Treasurers Unclaimed Propertyclaims rules require you prove relationship to claim unclaimed property of a relative who does nothave a surviving spouse. See http://missingmoney.com___________________________________________ ___________________________________________Your Mother’s full name Deceased?____ Your Father’s Full Name Deceased? _______________________________________________ ___________________________________________Your Mother’s mother’s full name Deceased?____ Your Father’s Full Name Deceased? _______________________________________________ ____________________________________________Your Mother’s father’s full name Deceased?___ Your Father’s Father’s Full Name Deceased?__ HireLyrics Client Authorized Representative (Mandatory Returned Completed)I APPOINT THE FOLLOWING AUTHORIZED REPRESENTATIVE TO SPEAK TO ROXANNE GRINAGE OR A HIRELYRICSADMINISTRATIVE SERVICES STAFF MEMBER ABOUT MY HIRELYRICS CLIENT ACCOUNT ON MY BEHALF IN THE EVENTI AM UNABLE OR UNAVAILABLE TO SPEAK FOR MYSELF.Authorized Representative Full Name.Address including town, city, State and zip codeEvery telephone number to reach Authorized Representative_____________________________________________________________________________________________Every email address or Facebook I.D. for your authorized representative____________________________________________________________________________________________What is your relationship? Why do you trust them to act as your Representative Authorized to interact withRoxanne Grinage or HireLyrics staff regarding your HireLyrics Administrative Services Account? Long timefriend, heir or next of kin, served in military together or had some other shared life experience which birthedcamaraderie. Page 10 of 15 mandatory returned.
  11. 11. Mandatory 15 Pages must be returned.AGREEMENT IS MADE THIS DAY BETWEENI, (full name including middle name or initial) ________________________________________________________,____________________________________________________________________________________________mailing address with town, city, state and zip code____________________________________________________________________________________________,telephone numbers_______________________________________________________________, email address, website face book id______________________________________________________________________ having read understand andagree. and/or [One or Two People with the same purpose can enter into this HireLyrics Form of Employment AgreementI, (full name including middle name or initial) ________________________________________________________,____________________________________________________________________________________________mailing address with town, city, state and zip code____________________________________________________________________________________________,telephone numbers_______________________________________________________________, email address, website face book id______________________________________________________________________ having read understand andagree). and Roxanne Grinage dba HireLyrics Administrative Services and U.S.Citizens Public Docket Database having a U.S. Postal Service Business registered Post OfficeBox 22225, Philadelphia Pa 19136; Pennsylvania Department of State Corporation Bureau assigned04/27/2001 Business Entity Filing Number Microfilm Number: 2001033 and a U.S. Department of TreasuryInternal Revenue Service 07/18/2000 assigned FEIN Tax I.D. Number shown on statements and invoices; andRoxanne Grinage and HireLyrics.org dba U.S. Citizens Public Docket Database having a PennsylvaniaDepartment of State Corporation Bureau assigned 02/16/2010 Business Entity Filing Number, andHireLyrics™ having a Commonwealth of Pennsylvania Department of Revenue Bureau of Business Trust FundTaxes Registration Division assigned 03/02/2004 Business Tax Acct I.D.: shown on sales receipts andCertificate of Registration Wholesaler Certificate posted where event and convention bulk order promotionalitems are produced and shipped; and Roxanne Grinage Manager of HireLyrics having earned PennsylvaniaDepartment of General Services Bureau of Minority and Women Business Enterprise assigned 08/26/2005Certificate No. 070831Hirelyrics Pennsylvania Department of General Services, Minority Women BusinessEnterprise Certified Expert 2003-2007 for “presenting documentation” that HireLyrics is “providing productsand/or services” in nine administrative support practice areas: PADGS Code 96159 Legal Services: EvidenceGathering, Depositions and Expert Witness Testimony; PADGS Code 91885 Personnel EmploymentConsulting (Human Resources); PADGS Code 95238 Employee Assistance Programs; PADGS Code 95239Employment Generating Activities; PADGS Code 94682 Tax Services Including Tax Advisory Services; PADGSCode 96225 Copywriting Services; PADGS Code 95238 Employee Development Consulting; PADGS Code96220 Career Consulting; PADGS Code 91725 Image Consulting; and Roxanne Grinage was FBI approved(now expired) Top Security Clearance while working for Honeywell Information Systems McLean, Virginia,and Roxanne Grinage’s Internal Revenue Service PTIN CAF numbers assigned fingerprints taken and onrecord at Internal Revenue Service Center, (Roosevelt Blvd.), Philadelphia Pa 19255, AGREE IN GOOD-FAITH AND GOOD-WILL to enter into a lawful business relationshiphereafter referred to as Effective/Mandatory 01/22/12 HireLyrics Form of EmploymentAgreement Retain Roxanne Grinage Legal Administrative Assistant Project Manager Option1 Standard Pro Se Document Production Claims Forms and Certified Service Notice, complies Page 11 of 15 mandatory returned.
  12. 12. Mandatory 15 Pages must be returned.with U.S. states statutes and Internal Revenue Service Business Registration and Tax Reporting Laws and is afurther demonstration of Wharton Small Business Administration 2001 nominated Philadelphia 100,HireLyrics invention in business method practice model simultaneously coordinated four divisions:Marketing Careers Label Stores, five departments: Overview & Rationale (The Gate Keeper), Client Accounts(HireLyrics Gear Package), Claims Intake (HireLyrics Evidence Package), Tax Prep & Tax Amendments, andOperations (Security Facilities Personnel Equipment Event Technology).Effective/Mandatory 01/22/12 HireLyrics Form of Employment Agreement Retain RoxanneGrinage Legal Administrative Assistant Project Manager Option 1 Standard Pro Se Document Production Claims Forms and Certified Service NoticeCOMPLIES WITH NEW FEDERAL LAWS AND CONGRESSIONAL ACTS. (1) The Federal Courts Jurisdiction and Venue Clarification Act of 2011, H. R. 394, P.L 112-63 (the"Act") (December 7, 2011), contains significant changes to the removal statute, 28 U.S.C. § 1441, and willaffect nearly every new case filed or removed next year invoking the courts’ diversity jurisdiction. The Act,and its numerous changes, take effect on January 6, 2012. The law will apply to all new state and federallawsuits commenced on or after that date. Congress addressed several areas of statutory confusion anddisagreement among various courts. The Act makes a variety of other changes to supplemental jurisdictioninvolving unrelated state claims, suits between aliens, and residency of non-resident aliens and foreigncorporations for venue purposes. Judges, federal practitioners and students of civil procedure will also notethe law’s reorganization of the jurisdictional statutes found in Title 28 of the U.S. Code, which have beengraciously simplified for clarity. See Appendix A. (2) The National Defense Authorization Act for Fiscal Year 2012 as reported to senate including FeinsteinAmendment Section. 1031. (U.S. Citizens can be imprisoned without trial) ─ An original bill to authorizeappropriations for fiscal year 2012 for military activities of the Department of Defense, for militaryconstruction, and for defense activities of the Department of Energy, to prescribe military personnelstrengths for such fiscal year, and for other purposes, as introduced and AFFIRMATION OF AUTHORITY OFTHE ARMED FORCES OF THE UNITED STATES TO DETAIN COVERED PERSONS PURSUANT TO THEAUTHORIZATION FOR USE OF MILITARY FORCE.Roxanne Grinage Quality of Life Impacts for Americans Commentary: “Detention under the law of warwithout trial until the end of the hostilities authorized by the Authorization for Use of Military Forceoptimizes risk of records mismanagement, disallows measurement of individual accountability such thatrampant abuses are likely to threaten survival of America as a populated sovereign nation and certainlythrust a former world power into the dark ages of despotism.” – respectfully Roxanne Grinage. See AppendixB. NDAA Feinstein Amendment Section. 1031http://en.wikipedia.org/wiki/National_Defense_Authorization_Act and 926 pageshttp://www.gpo.gov/fdsys/pkg/BILLS-112s1867es/pdf/BILLS-112s1867es.pdfRE THIRD PARTY REFERRALS: I UNDERSTAND IF I AM A THIRD PARTY CONSULTANT OR PROFESSIONALSERVICE DESIRING ROXANNE GRINAGE TO AUTORIZE A REFERRAL TO MY COMPANY OR THIRD PARTYCONSULTANT SERVICES IN HIRELYRICS AUTORIZED TEAMS OF THIRD PARTY PROFESSIONAL SERVICESREFERRALS ROXANNE GRINAGE MAY OUTSOURCE THE PERSONAL SECURITY DISCOVERYINVESTIGATIVE FORENSICS LABORATORY EXPERT WITNESS LAWSUIT COORDINATOR OR LAW FIRMREFERRAL IN THE BEST INTEREST OF A HIRELYRICS CLIENT, THAT I KNOW THIS HIRELYRICS FORM OFEMPLOYMENT AGREEMENT DOES NOT APPLY TO ME AND I MUST PRESENT ROXANNE GRINAGE WITHWRITTEN EXPRESSION OF INTEREST AND ANY PROFESSIONAL SERVICES AND FEE SCHEDULES,SUGGESTIONS OF CONTINGENCY CONTRACTS THAT APPLY BEFORE ROXANNE GRINAGE WILLCONSIDER REFERRALS OF ANY HIRELYRICS CLIENT ACCOUNT TO ANY THIRD PARTY PROFESSIONALBUT THAT ROXANNE GRINAGE DOES ENCOURAGE ALL ETHICAL QUALIFIED LAW FIRMS LAWYERS, Page 12 of 15 mandatory returned.
  13. 13. Mandatory 15 Pages must be returned.SPECIAL PROSECUTORS, INTELLIGENCE OFFERS, LAW ENFORCEMENT, PRIVATE INVESTIGATORS,SECURITY AND SURVEILANCE PERSONNEL, LABORATORY AND FORENSICS PROFESSIONALS TOPLEASE MAKE THEIR AVAILABILITY AND CREDENTIALS KNOW TO HIRELYRICS ADMINISTRATIVESERVICES FOR THE SAKE OF MECHANIZED REFERRALS EN MASS FOR THE STANDARDLY PRESENTINGLEGAL ADMINISTRATIVE ASSISTANT VERIFIED FEDERAL CRIME VICTIM CLAIMANTS WHOSE EVIDENCEGATHERING DEPOSITIONS AND EXPERT WITNESS TESTIMONY VERIFY MERITS OF CLAIM.I understand by returning Effective/Mandatory 01/22/12 HireLyrics Form of EmploymentAgreement Retain Roxanne Grinage Legal Administrative Assistant Project ManagerOption 1 Standard Pro Se Document Production Claims Forms and Certified ServiceNotice, Federal Crime Victim Disclosure, Form COL Legal Notice and Warning Violation ofRights Under Color of Law, Unclaimed Property, HireLyrics Client Authorized Representative,HireLyrics Client Data Sheet, Proof of my Identity Documents, HireLyrics Response Work OrderQueries (Yes or No answers) mandatory Authorized Representative completed pages signed infront of a Notary Public, Authorization Release of Information, Revocation Authorization Releaseof Information; and Execution Signature Page, indicate that I am expressing my application toRoxanne Grinage to be authorized accepted as a HireLyrics Client. I understand RoxanneGrinage is not obligated to perform Professional Services on my behalf but reserves to the rightto perform services awaiting payment if I have urgently requested Roxanne Grinage to act asmy legal administrative assistance or project manager retained by this Effective/Mandatory01/22/12 HireLyrics Form of Employment Agreement Retain Roxanne Grinage LegalAdministrative Assistant Project Manager Option 1 Standard Pro Se DocumentProduction Claims Forms and Certified Service Notice.I understand Roxanne Grinage is not a lawyer. Roxanne Grinage is not an attorney and cannotrepresent any person in a court process. Roxanne Grinage can only provide court and claimsprocesses compliant pro se document and exhibit production that the independent creator,federal crime victim of official corruption fraud civil rights American victim who becomes aHireLyrics Client within a form of HireLyrics Professional Services Agreement that the Americanclaimant files on their own behalf pro se. Roxanne Grinage commits to monitoring courtcalendar, performing docket analysis and seeking the assistance of respected third partyprofessional services that could include lawyers and law firms but are more likely to be veteranexperienced legal secretaries, paralegals, lawsuit coordinators, private investigators, retired oroff duty police officers, security firms and any combination of independent creators HireLyricsclients and collaborators spanning every demographic currently known to HireLyrics StandardAccess to Legal Administrative Assistant Services regardless of who you know or what youhave.I am in the process of getting photocopies of mandatory/required identity documents listed onHireLyrics Client Data Sheet, returned to Roxanne Grinage and understand that RoxanneGrinage cannot produce any documents claim forms or make telephone calls as my hired legaladministrative assistant or project manager until I provide proof of my identity to RoxanneGrinage HireLyrics Administrative Services U.S. Citizens Public Docket Database.I know myself and my family to be Federal Crime Victims having verifiable claims of OfficialCorruption Fraud Civil Rights violations in accordance with U.S Attorney General’s definition ofOfficial Corruption Fraud Civil Rights.I certify I am a Federal Crime Victim* as defined by United States Department of Justice as setforth in 18 U.S.C. § 3771: * ACCORDING TO THE ACT, A VICTIM IS “A PERSONDIRECTLY AND PROXIMATELY HARMED AS A RESULT OF THE COMMISSION OF AFEDERAL OFFENSE OR AN OFFENSE IN THE DISTRICT OF COLUMBIA. IN THE CASE Page 13 of 15 mandatory returned.
  14. 14. Mandatory 15 Pages must be returned.OF A CRIME VICTIM WHO IS UNDER 18 YEARS OF AGE, INCOMPETENT,INCAPACITATED, OR DECEASED, THE LEGAL GUARDIANS OF THE CRIME VICTIMOR REPRESENTATIVES OF THE CRIME VICTIM’S ESTATE, FAMILY MEMBERS, ORANY OTHER PERSONS APPOINTED SUITABLE BY THE COURT, MAY ASSUME THECRIME VICTIM’S RIGHT UNDER THIS CHAPTER, BUT IN NO EVENT SHALL THEDEFENDANT BE NAMED AS SUCH GUARDIAN OR REPRESENTATIVE.”I, certify that I have acted lawfully responsibly and respectfully throughout all corruptionpoisoned processes and venues and continue to act lawfully as a proud resident of UnitedStates, committed to leveraging individual accountability forbidding abuse of immunity languagein 1983 Civil Rights Act which is being used by criminally behaving official corruption fraud civilrights assailants to perpetrate felony crimes upon working class student and impoverishedfamilies to perpetrate a Child Slaughter U.S. Economy Fraud Court and Education ReformPublic Safety State of Emergency in my state and our nation.I swear under penalty of perjury that I know I am a Federal Crime Victim created by OfficialCorruption Fraud Civil Rights malpractice conflict of interest and in some cases RacketeeringCorrupt Organization (RICO) inflicted upon myself my family and/or my business interests.I swear under penalty of perjury that I have a greater vested interest than does any state agencyemployee, corrupt Domestic Relations Judge, or CPS/DHHS/OCS/ACS/DCF billing contractor inmy own U.S. Economy enriching original work contributions including my family’s persons,heritage, health, freedoms, education and U.S. economy enriching careers contributions.I believe I am disadvantaged for fairly entering and competing in those market places,particularly litigation of pro se claims and crime victim compensation, which would empower meto guard rights of ownership to my civil state and U.S. Constitutional rights to due process sothat I might preserve my civil rights to have some say into how my contributions of heritage,health education careers and vested interest consume disseminated transported and billed forthroughout industry buyers and consumers of Litigation, Education, Technology, Engineering,Military/Defense, Healthcare, Space Travel, Architecture Engineering and Bioengineering,Science, Addiction Recovery, Community Development, Entertainment, Media, Advertising,Commerce, Mentorship, Environmental Production, Medicine, Healthcare, Business Start Upand Development, and Public Safety, etc.I understand Roxanne Grinage is not a lawyer. Roxanne Grinage is not an attorney and cannotrepresent any person in a court process. Roxanne Grinage can only provide court and claimsprocesses compliant pro se document and exhibit production that the independent creator,federal crime victim of official corruption fraud civil rights American victim who becomes aHireLyrics Client within a form of HireLyrics Professional Services Agreement that the Americanclaimant files on their own behalf pro se. Roxanne Grinage commits to monitoring courtcalendar, performing docket analysis and seeking the assistance of respected third partyprofessional services that could include lawyers and law firms but are more likely to be veteranexperienced legal secretaries, paralegals, lawsuit coordinators, private investigators, retired oroff duty police officers, security firms and any combination of independent creators HireLyricsclients and collaborators spanning every demographic currently known to HireLyrics StandardAccess to Legal Administrative Assistant Services regardless of who you know or what youhave.I understand Roxanne Grinage is the owner and manager of twelve years demonstratedPennsylvania Secretary of State and U.S. Department of Treasury registered invention of Page 14 of 15 mandatory returned.
  15. 15. Mandatory 15 Pages must be returned.business method, HireLyrics Administrative Services, whose practice models demonstrate “Theanswer to missed educational opportunities, oppressive contracts, un-accountability horrorstories, racism, poverty and hate-based ideas festering into terrorism is the responsibledevelopment of entities that standardize access and standardize services.”HireLyrics is Born To Serve the previously unmeasured un-accommodatedWorldwide Population of Disadvantaged Creators© of original creative work products.See HireLyrics Schematics reported to Pennsylvania Secretary of State ContractsAdministration, U.S. Department of Treasury, Whitehouse Executive Officers, Top Ten BusinessSchools, Scholars and Global Think Tanks 2005. Free Download Re-posted 10/20/11 BuildThis! Roxanne Grinage almost twelve years Prototype Demonstrated Standard Access PracticeModel Schematics Reported at Fifth Anniversary 2005 birthed Administrative Solutions ToolU.S. Citizens controlled Public Docket Database Corruption in Government Clean Up ChildSlaughter U.S. Economy Fraud Court Education Reform Public Safety Emergency.pdfhttps://docs.google.com/open?id=0B-34Z89xij26NGZhYzc5NTMtYWEwMi00Y2MyLWE2OTYtYTdiODI5OWRmODFlIN WITNESS WHEREOF, the party or parties by their OWN HAND authorized representativeshave executed this Employment Agreement as of the Effective Date a total of thirteen pagesprecede this EXECUTION SIGNATURE PAGE REQUIRED SIGNED IN PRESENCE OFNOTARY.HireLyrics Disclosures and Disclaimers, Terms and Conditions including Termination for Cause,Fees Payment Arrangement Payment Options, Duration, Confidentiality and PrivacyDisclosures and Table of Contents are forty-six pages and available for free download atwww.HireLyricsorg and printing at any time at www.HireLyrics.org/roxannegrinageresume.html.Signature SignaturePrinted Name Printed NameMailing Address including city state and zip code Mailing Address including city state and zip codeSTATE OF ______________ )COUNTY OR DISTRICT )________________________ )Subscribed and sworn to or affirmed before me at (city), (state) On (date).(NOTARY SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. ______________________________________________________________________ My commission expires: Page 15 of 15 mandatory returned.

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