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State of	, County of	}ss.
Worker's Verified Statement and Notice to Terminate Form W-4 Agreement (or its equivalent) and Notice to Revoke Previous Withholding Authorization
[26 CFR $ 31.3402(p)-1, IRS Publication 15 page 14; Publication 505 pgs. 10 and 11; and Publication 515 pgs. 2, 3, 4]
Notice to Agent is N oti:e to Principal, Notice to Principal is Notice to Agent
Make this document a permanent attachment to the current W-4 (or its equivalent) maintained by Entity.
N OTI CE TO: Entity name	,
Attn:
	,	title,
Entity address ___________________________________________________________________
city, state, zip______________
an Entity,
created and organized within one ofthe united States of America; having no lawful authority to take amounts from my pay without my explicit, voluntary, written consent.
FROM: Worker's name	,
	------------
mailing location ____________________________________________________________________
city, state, zip
an inhabitant
------------------------------------
of one ofthe united States of America; and not consenting to have amounts taken from my pay without my explicit, voluntary, written authorization.
I am at least 18 years old and competent to testify to the filets stated herein based on my knowledge.
This verified Statement is in reference to working for the Entity, regarding the disclosure ofa social security number; completion of government forms; unauthorized taking amounts from pay for all federal and/or state
government taxes, programs, insurance and trusts, including non-judicial levies, garnishments, offsets, interest or penalties.
Upon my review ofthis d ocumen t, I have determ ined I have fully complied with the law, includ ing all applica ble federal and/or state statutes and regulations.
This is my OFFICIA L NOTIC E AND D EMA ND to the Entity to immediately discontinue taking a mounts from my pay without my voluntary, explicit, lawful consent.
I have based my determination on the following facts and law:
A.
The law [26 CFR * 31.3402 (p)-1 Volunta ry Withholding Agreem entsJ	(a) An employee who desires
to enter into an agreement fa r withhold ing	shall furn ish his employer with Form W -4 (or equ ivalent)
for withholding and (b)(2) Either the employer or the employee may terminate the agreement by furnishing a signed written notice to the other....
B.
Pursuant to 26 USC * 3402 (p)(3)(A), * 5517 and 31 CFR *215.2(n)(1), I do not consent to enter into a voluntary withholding agreement with the Entity nor do I voluntarily elect to have amounts
(02002,2003 Preferred Services $M _ W-4 Worker's Noticeto Terminate Agreement PO Box32009 Long Beach, CA 90832-2009_ 2003-10-23
Page 1 of 4 - WTP #1

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C.

taken from my pay for federal and/or state taxes, social security, other governmental insurance programs or welfare programs.
Pursuant to 26 CFR * 31.3402(p)-I(b)(2), either the Entity or the worker may terminate the withholding agreement (or its equivalent) at any time, by furnishing a signed, written notice to the other.

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D.

"The Com pany is not au thorized to alter the form [W-4 a r its equivale ntJ or to dishonor the worker's claim. The certifica te goes into effect autom aticaUy" (U.S. Distric t Court Judge Huyett, United States v. Malinowski, 347 F. Supp. 352 in 1992.

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E.

"... the withholding party is not responsible for misstatEments made on form (W-4 or equivalent) by an owner of income and hence would n at be liable for tax wh ich shou ld have been withh eld. Defen dants manifest courtesy as to whether the plaintiffwould pay tax... but this is none of their concern." Holmstrom v. PPG Industries, 512 F.Supp 552, 554 DC WD Pa. 1981. Also see: Murray v. City of Charleston 96 U.S. 432 (1877).

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F.

The current Form W -4 (or its equivalent) in the Entity's possession was submitted pursuant to IR Code *3402(n). It was not filed voluntarily. Its submittal was compelled as a condition of being hired by the Entity. When I did not complete and sign it, I may have unlawfully been refused work or to be paid; or I could have been wro ngfully terminated.

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G.

I am a "Protected Individual" as defined at 8 USC *1324b(a) (3)(A) and I cannot be compelled to submit any specific government documents or to disclose a social security number as a condition of being hired by or maintaining a position with the Entity.

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H.

1.

Pursuant to Department of Justice Form 1-9 (or equivalent), it is illegal to discriminate against work eligible men and women. Entities CANNOT specify which document(s) they will accept from a worker
In the landmark decision of EEOC v. Information Systems Consulting CA3-92-0169T U.s.D.C. Norther n District of Texas Dallas Divisio n, Entities cannot discriminate against applicants or workers for failure to obtain or disclose a social security number.

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J.

No law requires a worker to file a Form W-4 (or its equivalent). In U.S. v. Mobil Oil Co., 82-1 USTC para. 9242, U.S.D.C. ND Tex. Dallas 1981 CA. 3-80-0438-G, the court ruled that an Entity does not even have to send a W-4 Form or other employment forms to the Internal Revenue Service unless served with a judicial court-ordered summons to do so.

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K.

It is my understanding, pursuant to IRC *6041 (c), I am only required to furnish my name and address upon demand ofthe Entity. No social security number is required by statute.

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L.

According to State statute, no city, county, city and county, governmental subdivision, district, public and quasi-public corporation, municipal corporation, whether incorporated or not or whether chartered or not, shall levy or collect or cause to be levied or collected any tax upon the income, or any part thereof, of any person, reside nt or nome sident.

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M.

Absent a valid, order ex ecuted from a court of competent jurisdiction, the Entity has no lawful au thority to take amounts from my pay for non-judicial gamishments, levies, interest and/or penalties without my written consent. I do not consent to any such taking from pay.

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N.

I do not consent to participate in any federal and/or state offset program regarding government liabilities, debts or obligations. I do not consent to taking from pay for any offsets.

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O.

Under IRC *6301, the Entity, acting as a "tax collector," has not provided evidence of having a written delegation of authority from the Secretary to collect from me, the taxes imposed by the internal revenue laws. No implementing regulation exists under 26 CFR.

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(Q 2002, 2003 Preferred Services $M _ W-4 Worker's Noticeto Terminate Agreement PO Box32009 Long Beach, CA 90832-2009_ 2003-10-23

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P.

Under IRC *6201, the Entity, acting as an "assessment officer," has not provided evidence of having a written delegation of authority from the Secretary to make inquiries, determinations and assessments against me for the taxes (including interest, additional amounts, additions to the tax, and assessable penalties) imposed by 26 USC. No implementing regulation exists under 26 CFR.

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Q.

The authority ofa Withholding Agent (defined in **7701 (a) 16, 26CFR *301.7701-16) to withhold from one's payor remuneration (IRC **1441, 1442, 1443, and specifically in 26 CFR *1.14 41-7) applies to no nresident alien s. It does not apply to me.

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R.

S.

A Withholding Agent is required to have the specific Form 2678 on file with the IRS to be legally authorized to withhold from my eamings for the IRS, or a Form 8655 Reporting AgentAuthorizing Certificate from the Treasury Financial Management Service.
The En tity has not prov ided evidence of hav ing executed any forms 2678 or 8655 specific to me. This is significant as this is the only authority to withhold by a Withholding Agent as found in the law, and does not apply to me, since I am not a nonresident alien nor a foreign fictitious Entity. The Entity therefore has no filing or reporting requirement specific to me.

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T.

The published policies of the IRS in PublicatiDn 515 pages 2, 3 and 4 are clear in explaining that I am not subject to withholding of the income tax imposed in Subtitle A, and not subject to the jurisdiction for federal or sta te withholding.

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U.

Should the IRS assert that the Form 2678 and PublicatiDn 515 only applies to withholding from nonresident aliens, the Entity should seek an explanation as to what Form the federal government requires an Entity to have on file to be an authorized Withholding Agent regarding my rights and protections by both the Constitution for the united States of America and/or State Constitutions and/or Bill of Rights, unlike nonresident aliens who are under the charge of the federal government through their visa from the U.S. State D epartmen t.

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v.

State-federal agreements for administration of qualified state income taxes are authorized by Part 215 of 31 CFR. The authority applies exclusively to federal govemment agencies and personnel; it does not extend to general population in States 0 f the Union. Pursuant to 31 CF R * 215.9 and 26 USC Subtitle A, unless I voluntarily give written consent to have sums withheld, the Entity Jacks lawful authority to take amounts from my pay. I do not give my consent.

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W.

x.

Neither the Entity nor the State have provided any evidence of having entered into a Standard Agreement with the Secretary of the Treasury and Fiscal Assistant Secretary (or his delegates) pursuant to 31 CFR Subpart B-Standard Agreement *215.6 specific to me, regarding withholding for taxes from my earnings. I did not give my consent to the Entityto take amounts from my pay. The company compelled me to file Form W-4 (or its equivalent).
Neither the Entity nor the State have provided any evidence of having entered into a Section 218 Voluntary Agreement for coverage of social security specific to me, pursuant to 42 USC 418. I did not agree in writing to participate in any federal and/or state social insurance (trust) program. I do not consent to have amounts taken from my pay for social security coverage.

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Y.

I do not derive Subtitle A wage Gross Income (IRC ** 61, 911, and 26 CFR **1.861-4,1.61-2) and my remuneration does not constitute wages for withholding purposes under IRC *3401 (a)(8)(A)(i).

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z.

I do not derive taxable income as defined in 26 CFR *1.863-1 (c) from a taxable source defined in the operative section of 26 CFR *1.861-(f)(i). I am not engaged in a revenue taxable activity, event, or commodity. I am outside the venue and the jurisdiction of 26 USC and 26 CFR.

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AA

"Where rights secured by the Constitution are involved, there can be no rule making or legislation which would abrogate them." Miranda v. Arizona, 384 U.S. 436,491. Federal and/or state withholdings from my remuneration can only be accomplished by giving my voluntary consent. I do not consent.

(Q 2002-2003 PrefelTed Services SM POBox 32009 Long Beach, CA 90832-2009 _Worker's Notice to Tenninate W-4_2003-10-23

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This statement establishes my earnings are "excluded" with respect to Federal income taxes imposed under
subtitle A of the Code, pursuant to 26 CFR * 31.3402(n)-1 certifying that:
I. I incurred no liability for inco me tax imp osed und er subtitle A 0 fthe Code for the prece ding year;
2. I anticipate I will incur no liability for income tax imposed under subtitle A for the current year;
3. I have a righ t to a full refund of all amounts withheld without my voluntary consent.
4. Pursuant to 26 CFR *31.3402(p)-I, I DO NOT CONSENT to have amounts taken from my pay.
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With respect to Internal Revenue Code * 3101, Federal Insurance Contributions Act (commonly known as
Social See urity), this also estab lishes my "non-c overed worker" status certifying that:
I. I do not derive income taxable under 26 USC * 3101 and am therefore classified as "non-covered" worker; 2. I have never been made liable for any such tax pursuant to 26 USC * 6201;
3. I have never been issued any lawful assessment for any such tax, pursuant to 26 USC *6203;
4. Pursuant to 26 USC * 3402(p)(3) I DO NOT CONSENT to have amounts taken from my pay.
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	NOTE: Let me further remind the Entity that no computer-generated IRS letter or contrary advice from a tax
	professional or an attorney shall abrogate or supercede my sworn statement and the clear language and intent of the law as
9 I shown herein. Based on the law and facts, the Entity lacks legal authority or basis for withholding any federal or state
	"income" taxes, "emplo yment" taxes, "s ocial security" deductions 0 r excises from my pay withou t my written cons ent.
10 I The Entity will rely upon this verified statement to immediately cease and desist unlawful!y taking amounts from
	my pay absent my voluntary, written consent.
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	Should the Entity decide to continue to deprive me of my personal property (pay) for any reason other than a
12 Ijudicial order issued by a court of competent jurisdiction, I will pursue all available remedies to protect my rights and my
	property.
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	IN WITNESS, WHEREOF, I solemnly affirm, I have read the foregoing, and know the contents thereof to be true to the
14 I best of my knowledge, exc ept as to the matters which are therein stated on my information or belief, and as to those
	matters, I believe them to be true. This instrument is submitted upon good filith effort that it is grounded in fact, warranted
15 I by existing law for the modification or reversal 0 f existing law and submitted for prop er purposes, and no t to cause
	harassment and unnec essary delay or costs.
	16 I All rights reserve d under the law.
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Date
Signed________________________________________________
	(W orker' s signature)
---------------------
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ENTI TY: A ttach this d ocumen t to the cu rrent Form W -4 (or its eq uivalent) in the rec ords yo u mainta in on me. This docume nt is to remain a pe rmanent rec ord in my files.
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ACKNOWLEDGMENT
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Subscribed and affirmed to before me,	, a Notary Public, this _________
day of	,2003, that the above-named person did appear before me and proved to be the
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P
erson ex ecutin
g
this do cument. 26 '
My commission expires: _____________
27 I	,Notary Public
	------------------------------------------------
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(Q 2002-2003 PrefelTed Services SM POBox 32009 Long Beach, CA 90832-2009 _Worker's Notice to Tenninate W-4_2003-10-23
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