Information for Individual Making Statement Name Street Address City State Phone Social Security Number Describe complaint details Signature of Individual Making Statement I HEREBY ATTEST THAT ALL OF THE WRITING ABOVE ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE, AND FULLY UNDERSTAND THAT I AM ACCOUNTABLE FOR THIS STATEMENT THROUGH O.R.C. CODE 2921.13.Furthermore, I, the undersigned, hereby understand that this form is a legal document and all statements, accusations and recollections of any kind included within this document are true and accurate.I have read statement which bears my signature. Any corrections that have been made bear my initials and I declare that the facts contained within this statement form are true and correct. Leave this field blank