John-Henry: Doe c/o P.O. Box 01231, City, State 
Date: ___/___/ 20___
AFFIDAVIT OF MISTAKE
The undersigned Affiant, John Henry Doe, hereinafter, “Affiant” being of sound mind and over the age of twenty-one, knowingly and willingly declares and duly affirms, according to law, in special appearance and also does herewith assert and declares to be competent and willing to testify to the facts herein that Affiant issues this Affidavit of Mistake. Affiant further attests to the contents as true, correct, and complete in accordance with Affiant’s knowledge, understanding, and belief.
Until the Constructive Notice of Demand For Direct Challenge to Personal Authority dated 00/00/20__, is proven by the parties named therein, Affiant hereby revokes Affiant’s signature off of any and all Form 1040 U.S. Individual Income Tax Return’s, any State Individual Tax Return’s, and any and all W-4 forms as well as any fruits thereof for any and all years. Any and all forms were mistakenly signed or authorized by John Henry Doe.
I, John Henry Doe, do attest to the facts stated on this Affidavit of Mistake to be true and accurate to the best of my knowledge and belief.
On this day came before me the Affiant attest and affirm the signature is true and complete on the foregoing affidavit. John Henry Doe the undersigned, upon proper identification, personally came before me a notary public and duly affirmed the truth of the foregoing Affidavit in my presence. The Affiant also acknowledged the signing thereof to be his own voluntary act and deed.
Signed this ____ day of ____________________, 20___ at _______________________.
My commission expires on: ________________________
By_________________________ seal: ___________________