CANCELLATION OF VOTER REGISTRATION WHEREAS, I,_______________________________, , am competent in my own affairs, an d over age of majority; and WHEREAS, I affixed my signature

on a Texas Voter Registration Application on or about ___________________________ for _________ County, State of Texas; and WHEREAS, there has been a mistake; and WHEREAS, I am not a resident of _____________ County; and WHEREAS, I am a non-resident of the United States; and WHEREAS, I am not a citizen of the United States under Article XIV amendment to the Constitution of the United States; NOW, THEREFORE, FOR AND IN CONSIDERATION of abandonment of all privileges and immunities provided under Article XIV amendment to the Constitution of the Unite d States of America, I, _____________________, hereby cancel, rescind, and revoke, said Texa s Voter Registration Application. Any rights, privileges or obligations under said Texas Voter Registration Application are hereby terminated and released and fully and completely forever discharged. I request the name be removed from the official list of eligible voters in all mun icipal, county, state, and federal jurisdictions. Executed as my free will act and deed under my hand and seal this _____ day of _ _______________2012 _________________________________ (Seal) _________________________________ (Seal) , Witness Voter registration reference: YOUR NAME, D.O.B. CERTIFICATE OF ACKNOWLEDGEMENT State of Texas County of Harris

Before me, ________________________________, on this day personally appeared the living man, _____________________, proved to me through satisfactory evidence t o be the man whose name is subscribed to the foregoing CANCELLATION OF VOTER REG ISTRATION and acknowledged to me that he executed the same for the purposes and consideration therein expressed. Given under my hand and seal of office this _____ day of _______________________ _________ , 2012 (Seal) __________________________________ Notary Public in and for the State of Texas