HHS FORM 133A

Suicide Application

The Department of Health and Human Resources would like to earnestly thank you for applying for suicide, rather than illegally ending your own life without the proper Government approved authorization.  We know that you are eager to permanently put an end to your problems and have decided to stream line the process by eliminating the national suicide hotline and replacing it with the form you see before you.  Please answer all of the questions honestly and we will do our best to ensure a smooth transition from life to death.

Why are you committing suicide? (check all that apply)
__ Personal loss
__ To escape financial obligation
__ Spite/Revenge
__ Love,
__ Marriage
__ Loneliness
__ To prove a point (Political__ Ideological__ or Other__?)
__ Religion (mainstream__ or cult__?)
__ Overwhelming Sadness
__ Overdose (please check even if you aren’t intentionally planning to overdose, because accidents can happen)
__ Failed at life
__ Are an Emo
__Boredom
__To entertain others
__To avoid Federal prosecution
__Prefer not to disclose
__Other (Please briefly explain______________________________)

What Method are you planning to use, this is important as we need to know how you will end it all in order to dispatch a cleaning crew if you choose to kill yourself in a public place.  Again, please check all that apply.
__Firearm
__Firearm, assisted (Contact local law enforcement if you cant find a friend or family member to assist, or enlist in our military’s new alternative landmine removal program)
__Poison
__Automobile, personally operated
__Automobile, operated by others
__Explosives, Private
__Explosives, Public
__Exsanguination (May we suggest donating all of your blood instead of draining it yourself?)
__Choking
__Jumping off a building
__Jumping in front of a train
__Being Buried/Cremated Alive
__Starvation
__Poisoning
__Drugs (May we suggest that you volunteer for one of the Department of Drug enforcement Administrations “drug disposal” programs, we can assure you that they will attempt to dispose of as many drugs as possible in your body, and will also provide a complimentary cremation)
__Mutilation (May we suggest that you donate your still living body to science? Many Medical schools are in dire need of cadavers, and won’t mind getting one a little fresh.)
__Other, Please summarize the method of your suicide on the lines provided.
________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________

Are you planning on killing yourself in a messy and public manner? Yes___ No___.  Bear in mind that your next of kin will be billed for any clean up efforts necessary for your remains, so please be conscientious of how you dispose of yourself.

What will be the approximate time and Date of your suicide (bear in mind that this form takes an average 2-3 weeks to be processed, so please endeavor to plan a month ahead.)

Date __/__/__  Time  __:__

And finally, please specify the location of your suicide; both address and relative position (IE 314 Francis BLVD, New York, New York. Apartment 457, in the bathtub)
________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________

Thank you for taking the time to fill out this form, we will endeavor to have your request processed and authorized as promptly as possible.  In the mean time, please consider filling out your organ donor card and preparing your last will and testament.