Affidavit Pursuant to Ohio Revised Code Section 319.28

County of affiant name

Select whether the employment category applies to the affiant or the affiant's spouse

I am currently employed as a I am currently employed as a

Employment category

Peace Officer Parole Officer Probation Officer Bailiff Prosecuting Attorney Assistant Prosecuting Attorney Correctional Employee County or Multicounty Corrections Officer Community-Based Correctional Facility Employee Youth Services Employee Designated Ohio National Guard member Forensic Mental Health Provider Firefighter EMT Medical Director or Member of a Cooperating Physician Advisory Board of an Emergency Medical Service Organization State Board of Pharmacy Employee Investigator of The Bureau Of Criminal Identification And Investigation Judge Magistrate Federal Law Enforcement Officer Protective Services worker Mental Health Evaluation Provider Regional Psychiatric Hospital employee

Parcel numbers Dated Printed name Day of affidavit signing before notary Month of affidavit signing before notary Year of affidavit signing before notary Notary Public My commission expires