Ohio Admin. Code 117-5-04
"AFFIDAVIT (Type or print full name)
The undersigned, being ______ the auditor or ______ a county commissioner of ________________________ County, Ohio, hereby states as follows:
That, _________________________________, the treasurer of said county has purposely, knowingly, or recklessly failed to perform a fiscal duty expressly imposed by law, with respect to the fiscal duties of the office of county treasurer, or has purposely, knowingly, or recklessly committed any act expressly prohibited by law, with respect to the fiscal duties of the office of county treasurer.
The terms "fiscal duty expressly imposed by law" and "act expressly prohibited by law" may include a duty imposed by or an act prohibited by a statute contained within the Ohio Revised Code and/or an Ordinance or Resolution adopted by the board of county commissioners.
That the fiscal duty which,__________________________________, the treasurer of said county, has purposely, knowingly, or recklessly failed to perform, is expressly imposed by the following law(s):________________________________________.
or
That the act(s) which said aforementioned treasurer has purposely, knowingly, or recklessly committed is expressly prohibited by the following laws: _______________________________________________________.
The facts constituting the purposeful, knowing, or reckless failure of the said county treasurer to perform a fiscal duty expressly imposed by law, with respect to the fiscal duties of the office of county treasurer, or of the said county treasurer's purposeful, knowing, or reckless commission of any act expressly prohibited by law, with respect to the fiscal duties of the office of county treasurer, are as follows:
__________________________________________ Add additional pages as may be necessary.
Evidence supporting the foregoing allegations is as follows:
__________________________________________ Add additional pages as may be necessary.
BY SIGNING BELOW, YOU ARE SWEARING TO THE TRUTH OF THE ALLEGATION(S) AND THE AUTHENTICITY OF ALL DOCUMENTS AND EXHIBITS WHICH ARE DEEMED INCORPORATED HEREIN. ANY PERSON WHO KNOWINGLY MAKES A FALSE STATEMENT IN SUCH AN AFFIDAVIT IS GUILTY OF FALSIFICATION UNDER SECTION 2921.13 OF THE OHIO REVISED CODE, A FELONY OF THE THIRD DEGREE.
_______________________________________
SIGNATURE OF AFFIANT
Date: _______________________________________
TO CONSTITUTE A VALID COMPLAINT, THIS AFFIDAVIT MUST BE SIGNED BEFORE A NOTARY PUBLIC. FAILURE TO SIGN AND TO INCLUDE A PROPERLY COMPLETED JURAT (BELOW) WILL RESULT IN THE IMMEDIATE DISMISSAL OF THE COMPLAINT.
STATE OF OHIO)
______________) ss:
_______ COUNTY)
Before me, a Notary Public, in and for said county and state, personally appeared the Affiant identified above who, after having been first duly sworn pursuant to law, executed the foregoing document, and averred that the same was his own free act and deed, and that the content thereof is true to the best of his knowledge, understanding, and belief.
_______________________________________
NOTARY PUBLIC
My Commission Expires:"
Ohio Admin. Code 117-5-04
Five Year Review (FYR) Dates: 4/15/2021 and 07/01/2026
Promulgated Under: 117.20
Statutory Authority: 117.43, 117.45
Rule Amplifies: 117.43, 117.45
Prior Effective Dates: 11/16/2015