(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.