Declaration To Make To Census Takers:

I hereby affirm that the provisions of Title 13, Chapter 5 of U.S. Code requiring me to disclose my race, personal financial data, birth date, or any other personal, private information to the Bureau of the Census, an agency of the United States government, constitutes an unreasonable, unwarranted search of my person, house, papers, and/or effects, and a governmental invasion of the sanctity of my home and the privacies of life. As such, these provisions violate the Fourth Amendment of the U.S. Constitution, and are thus wholly void and I am not bound to obey them.

I have completed only those sections of the Census form pertaining to the Constitutionally-mandated actual enumeration (the U.S. Constitution, Article 1, Section 2), as follows:

1. The actual number of people living at the address printed on the form, excluding untaxed Native Americans;
2. Age of each person in accordance with the U.S. Constitution, Amendment XIV, Section 2;
3. Sex of each person, in accordance with the U.S. Constitution, Amendment XIV, Section 2.

I have thus fulfilled my obligation to the attainment of the actual enumeration of the populace of the United States.

Any fine or other sanction that is levied by any office or organization stemming from the unconstitutional provisions of Title 13 in connection with my response to this or any other Census-related questioning will be challenged as opposing the Constitution, the Supreme Law of the Land.