Sample Affidavit Form printable pdf download

AFFIDAVIT

(SAMPLE – DRAFT ONLY)

The State/Country of _________

)

) solemnly sworn

The County of _____________

)

I, __________[name], of _________[address], State, Country, MAKE OATH AND SAY

THAT:

The following facts are within my personal knowledge.

In 1998, I began to have heating sensations and headaches upon using a cell

phone. After several months, I ceased using a cell phone and never

experienced these symptoms again. Cordless phones in others’ homes

produced similar symptoms with usage, so I never purchased a cordless

phone. I did not mention these experiences to my children.

When a cell tower was placed next to my home in 1999, my children could

not sleep, and everyone in the family had headaches. Within a few weeks, we

had measured the RF/MW radiation and found its directionality, indicating all

of the measurable radiation was coming from the tower. Measurements were

below FCC guidelines. When we placed multiple shielding materials on the

side of the house where the tower was and cut the radiation down by 1,000x,

the symptoms subsided.

Wifi was installed with cords (wires) in my children’s schools in 2002. They

had no problems with it. When however the wired wifi was removed in 2006

and wireless wifi installed, my children had serious cardiac problems,

including sudden arrhythmias that occurred only when in school. They also

had headaches, difficulty concentrating, and memory problems. We removed

them from school and there was no further problem.

In 2008, family members began experiencing sleeplessness, headaches,

memory impairments and cardiac arrhythmias again. Upon measuring, we

learned the neighbor had wifi turned on 24-7. We provided the neighbor RF

radiation measurements. He then rewired his wifi, and disabled the wireless

function; and our symptoms subsided.

When two “smart” meters were installed against our specific refusal of them

in 2011, the entire family had even worse symptoms than before. We moved

from our home to live in an RV in an area of woods that is currently rather

free of RF radiation. We now do not use electricity except minimally by day;

therefore we are not at all connected to it by night. By living in this manner,

we sleep well and have no neurologic or cardiac problems.

Various physicians have documented our symptoms and diagnosed us with

related conditions, including Electromagnetic Sensitivity. In 2012, a case

study pertaining to my children was published in the peer-reviewed journal:

_____. [Exhibit 1]

FCC admits it has consulted with industry-funded groups including ICNIRP and

IEEE, in order to set exposure guidelines. These guidelines, per many studies,

even those chosen by ANSI-IEEE in 1991, show adverse effects at exposure

levels far below FCC guidelines.

The most recent review by a large group of independent scientists,

Bioinitiative 2012, concurs. [Exhibit 2]

10.

All biological organisms are subject to adverse effects from the current

ambient levels of EMR; and this is killing the bees and birds per these studies:

________ [Exhibit 3]

Sample Affidavit Form

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