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OHIO DEPARTMENT OHIO DEPARTMENT OF PUBLIC SAFETY ~~ OF PUBLIC SAFETY DIVISION OF HOMELAND SECURITY ~/!~.•~ EDUC~TION•SERVICE•PROTfiCT1OK httpJ/www.homelandsecur9ty.ohio.gov GOVERNMENT BUSINESS AND FUNDING CONTRACTS In accordance with section 2909.33 of the Ohio Revised Code DECLARATION REGARDING MATERIAL ASSISTANCElNONASSISTANCE TO A TERRORIST ORGANIZATION This form serves as a declaration by an applicant for a govemment contract or funding of material assistancelnonassistance to an organzation on the U.S. Department of State Terrorist Exdusion List {'TEL"}. 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 disdosure that material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List has been provided. Failure to disdose the provision of material assistance to such an organ¢ation or knowingly making false statements regarding material assistance to such an organization is a felony ofthe fifth degree. For the purposes of this declaration, 'material support or resources" means currency, payment instruments, other financial securities, funds, transfer of funds, financial services, communications, lodging, training, safe houses, false documentation or identification, communications equipment, facilities, weapons, lethal substances, explosives, personnel, transportation, end other physical assets, except medicine or religious materials. COMPLETE THIS SECTION ONLY IF YOU ARE AN INDEPENDENT CONTRACTOR LAST NAME FIRST NAME MI HOME ADDRESS CITY STATE ZIP COUNTY H(~MF PHnNF V4YlRK PHCINF COMPLETE THIS SECTION ONLY IF YOU ARE A COMPANY BUSINESS OR ORGANIZATION BUSINESS/ORGANIZATION NAME PHnNF BUSINESS ADDRESS S 7 ~ ~ ~ urr K- ~ ~ e_ C TY STATE ZIP COUNTY oa l~ o -~r~ yy~~2 Gvy aG~ BUSINESSlORGANIZATION REPRESENTATIVE NAME TIT E r /1cs i ~E u~~,~r~RH ~ ~urv 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 ^V~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 No 3. Have you knowingly solicited funds or otherthings of value for an organization on the U.S. Department of State Terrorist Exclusion List? ^ Yes 4 Have you solicited any individual for membership in an organization on the U.S. Department of State Terrorist Exclusion List? ^ Yes LJ ~~o 5. Have you committed an act that you know, or reasonably should have known, affords "material support or resources" to an organization on the U.S. Department of State Terrorist Exdusion List? ^ Yes Q 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 govemment contract or funding due to a positive indication on this form, 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 file a request for review. CERTIFICATION 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. 1 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 an 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 or my organization- If I am signing this on behalf of a company, business or organization, I hereby acknowledge that I have the authority to make this certification on behalf of the company, business or organization referenced on page 1 of this declaration. 3/10 Page 2 of 2