(A) The sworn affidavit and evidence submitted to the
office of the auditor of state pursuant to section 733.78 of the Revised Code
shall be in the following form and manner:
"AFFIDAVIT (Type or print full name)
The undersigned, being a member of the
legislative authority of the following village, to wit:
___________________________ , ________________________ County, Ohio, hereby
states that _________________________________, the or a fiscal officer of said
village has purposely, knowingly, or recklessly failed to perform a fiscal duty
expressly imposed by law, with respect to the fiscal duties of said office, or
has purposely, knowingly, or recklessly committed any act expressly prohibited
by law, with respect to the fiscal duties of said office.
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 controlling legislative
body.
That the fiscal duty
which,__________________________________, the fiscal officer of said village,
has purposely, knowingly, or recklessly failed to perform, is expressly imposed
by the following law(s):____________________________________________.
or
That the act(s) which said aforementioned fiscal
officer 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 fiscal officer to perform a fiscal duty
expressly imposed by law, with respect to the fiscal duties of said office, or
of the said fiscal officer's purposeful, knowing, or reckless commission
of any act expressly prohibited by law, with respect to the fiscal duties of
said office, is set forth herein below 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
__________________________________________________________________
ADDRESS OF AFFIANT
__________________________________________________________________
EMAIL ADDRESS OF AFFIANT
__________________________________________________________________
PHONE NUMBER 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:"
(B) For purposes of completing the affidavit, 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
any statute contained within the Ohio Revised Code and/or an ordinance or
resolution adopted by the controlling legislative body.
(C) Any such affidavit, together with any
supporting evidence accompanying the same, shall be delivered to the offices of
the auditor of state in Columbus, Ohio, or forwarded to the auditor of state at
said office, via certified United States mail with return receipt requested,
postage prepaid. The effective receipt of any such affidavit and any supporting
evidence accompanying the same shall be the date of actual delivery to and
receipt by the auditor of state.