2011-120 Ordinance - Laserfiche WebLink

Home Browse Search

Otu4 DEPARTMENT OHIO DEPARTMENT OF PUBLIG SAFETY ~~ of PUBLIC SAFETY DMSION OF HOMELAND SECURITY t:''~ j'~ •°~`"•'°" • """"` . •"°••"'°" MtpJ/www.h omelandseairity.ohio.gov DECLARATIDN REGARDING 6AATERIAL ASSISTANCEINONASSISTANCE TO A TERRORIST ORGANIZATION Ttus form serves as a declaration by an applicant for a government contr~t or funding of material assistencelnonassistance to an organ¢ation on the U.S. Department of State Terrorist Exclusion List {'fEL'}, Please see the Ohio Homeland Security Division Web site for a copy of the TEL. Any answer of'yes' to any question, or the failure to answer'no to any question on this declaration shall serve as a disclosure that material assistance to an organzation identified on the U.S. Department of State Terrorist Exclusion List has been provided. Failure to disclose the provision of material assistance to such an organ¢~on or knowingly malting false statements regarding material assistance to such an organization is a felonyofthe fifth degree. For the purposes of this declaration, 'material support or resources' means currency, payment instnxnents, other financal seaxities, funds, transfer of funds, financial services, communications. lodging, training, safe houses, false doaxnentation or iderrtification, communications egripmert, fadlities. weapons, lethal substances, explosives, personnel, transportation, and other physical assets, except medicine orreligrous materials. LETE THIS SECTION ONLY IF YOU ARE AN INDEPENDENT C~+ITRACTOR COMP LAST NAME FIRST NAME MI HOME ADDRESS CITY STATE ZIP COUNTY HnMF PHONF WORK PHONF COMPLETE THIS SECTION ONLY IF YOU ARE A COMPANY BUSINESS OR OR6ANIZAT1vN BUSINESS/ORGANIZATIONHAME n `' i~ PHONF -L. ~.~~~~t~N ~-~ G AAA Mi~ bN 1-6b1,~iC.. 33(7"~R~~22.~ BUSINESS ADDRESS 2~-;,1, o~.oc>r CITY STATE ZIP COUNTY ~~~n~ o~.o ~~ 3~a s ft.,w,: BUSINESSlORGANIZATION REPRESENTATIVE NAME TITLE ~~N ~J~Si >~w GOVERNMENT BUSINESS AND FUNDING CONTRACTS In a©coniance with seCtlOn 2909.33 of the Ohio Revised Cock DECLARATION In accordance with section 2909.32 (A)(2xb} of the Ohio Revised Code For each question, indicate either yes; or'no' in the space provided. Responses must be truthful to the best of your knowledge. 1. Are you a member of an organization on the U.S. Department of State Terrorist Exclusion List? ^ Yes Q No 2. Have you used any position of prominence you have with any country to persuade others to support an organization on the U.S. - - Department of State Terrorist Exclusion List? ~ ~! ~ Yes IJ nio 3. Have you knowingly solidted funds or otherthings of value for an organization on the U.S. Departrnent of State Terrorist Exclusion List? ^ Yes V~No 4. Have you solicited any individual for membership in an organization on the U.S. Department of State Terrorist Exclusion List? ^ Yes [ 'No 5. Have you committed an act that you know, or reasonably should have known, affords "materiel support or resources" to an ? organization on the U.S. Department of State Terrorist Exclusion List ~ Yes [~No 6. Have you hired or compensated a person you knew to be a member of an organization on the U.S. Department of State Terrorist Exclusion List, or a person you knew to be engaged in planning, assisting, or carrying out an act of terrorism? ^ Yes ~No If an applicant is prohibited from receiving a government contract or funding due to a positive indication on this inn, the applicant may request the Ohio Department of Public Safety to review the prohibition. Please see the Ohio Homeland Security Web site for information on how to fAe a request for review. CERTIFlCATION I hereby certify that the answers I have made to all of the questions on this declaration are true to the best of my knowledge. I understand that if this declaration is not completed in its entirety: it will not be processed and I will be automatically disqualified. I understand that I am responsible for the correctness of this declaration. I understand that failure to disclose the provision of material assistance to en organization identified on the U.S. Department of State Terrorist Exclusion List, or knowingly making false statements regarding material assistance to such an organization is a felony of the fifth degree. I understand that any answer of 'yes' to any question, or the failure to answer'no' to any question on this declaration shall serve as a disclosure that material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List has been provided by myself o y organization. tf 1 am signing this on bah a comp ny, business or organization, I hereby acknowledge that I have the authority to make this c ification on behalf of c pany,yr~ mess or org rzation referenced on page 1 of this declaration. 2.2