Form77A

HappinessInsuranceapplication
EmpoweringClerksNetwork,
DepartmentofWellbeing
39ZTV(477NBL92)

CommissionerofCompassion
NormanFischer

In order to increase the amount of paperwork in our healthcare system, an ECN committee has decided to offer a Happiness
Insurance. Form 77A is for people who wish to apply for a Happiness Insurance Plan. One must be eligible to experience
happiness once or moreoften inagivenweek.If you have a preexistingconditionyoumay specifyitbelow.Please notethat an
ECN JoyPermit (JP33)is not necessary to experienceHappiness
.ECNCSB UNITEDisa progressiveRFE(RegisteredFictional
Entity), and the first onetoallow Happinessinsurance applicantsto choose more than one Happiness provider. Once approved,
you may file happiness reduction claims through contacting your providers. Your annual deductible is affected by your Annual
Karma Report (AKR77D, a formless form) and your chosen copay method. Please note that neither the ECN nor the CSB is
responsible foranyhappinessloss youmay experience prior orsince filingup this application.
Experiencing Happinesswithouta
validHappiness Insurance Card can cause relief andaddiction. Your insurance cardwillarrivewithanECNPainDeed(Individual
SufferingTitle)andyoumayfileitforyourrecords.Pleaseprint.

Name:______________________________DOB(approx.):_____________________HappinessLevel(110):_________
Address:____________________________________________________Wellbeingstate:_________________________
Email:_________________________________nickname:____________IvereceivedECNservicesinthepast:yes/no

1
.WhichHappiness
providers
Ichoose?(markatleastthreeareasthatprovideyoujoy)

Self(acceptance,growth,understanding)

Family

Friends

Community

Spirituality(religion,meditation,faithetc.)

Nature(hiking,animals,gardeningetc.)

Action(politicalorsocialchangeactivity)

Art(consumingreading,watchingmoviesetc.)

Selfexpression(producingart,work,hobbyetc.)

Individualsinmylife(name):______________________________________________________

Other:________________________________________________________________________

2
.HowmanyHappinessreductionclaimsImadeinthelastyear?
a
.Toomany.
b
.Justenough.
c
.Veryfew.
d
.Ilostcount.

Form77ACenterforSupportiveBureaucracy
39ZTV(477NBL92)

supportivebureaucracy.org1/2
ReturningMedicinetoPeopleMichaelOBrienMDmichaelobrienmd.com

3
.CopaysareactionsI'mnotthrilledaboutbutdoinordertomaintainbalancedHappinesslevel.
WhatcopaysmethodamIinterestedinusingformyplan?(youmaychoosemorethanonemethod)
a.
selfwork(therapy,coachingetc.)
b.
Relationshipinvestment
c.
Spiritualpractice(davening,meditationetc.)
d.
Physical(exercise,hikingetc.)
e.
Otherpleasespecify:___________________________________

4
.Happinessformeis:______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5
.HowmuchmoreHappinessIwishtoexperience?(comparedtohappinessexperienceinfilingdate)
a.
0%25%
b.
25%50%
c.
50%75%
d.
75%100%
e.
Morethan100%
f.
Ineedtoaskmypartner

6
.Imaspecialistat:_________________________________

7
.Idliketoexperiencehappinessbecause:
a.
Iveexperienceditinthepastanditwasbeneficialforme.
b.
InoticedotherpeopleexperiencingitandIwouldliketotrythattoo.
c.
Imtryingtoavoidtheemotionaltaxpenalty
d.
other:____________________________________________________________________________________________
___________________________________________________________________________________________________

IgivepermissiontoECNtousemyanswersforresearchandartisticpurposes.

Idliketokeepmyinformationconfidential.

Thank you.Please mail to EmpoweringClerksNetwork(Attn:ProcessingDepartment),60 AndersonSt.,BeaconNY12508or to

alfassibooks
@gmail.com
. The Empowering Clerks Network (ECN) is a Loving & Liable Entity (LLE) that specialize in issuing
official Playful Paperwork documents. Together with the Center forSupportiveBureaucracy(CSB) weissue Forgivers License
(Class A&B), Joy Permit, Refurbished Report Cards, Pain Deeds, OK Parent Award, True Friend Diploma and more. After
receiving your Happiness Insurance card by mail (within 23 weeks) you maychooseto supporttheECN or
pay itforward to
benefit a good cause you believe in with your time, money or talent.
supportivebureaucracy.org

Forapplicantuseonly:

Iagreetosupportotherhumanbeings.

IwanttoJoinECNasanEmpoweringClerk.

haveaquestion/concern/realization:

________________________________________________________________
________________________________________________________________
________________________________________________________________

Form77ACenterforSupportiveBureaucracy
39ZTV(477NBL92)

supportivebureaucracy.org2/2
ReturningMedicinetoPeopleMichaelOBrienMDmichaelobrienmd.com