Affidavit

NOW COMES ______________________, being first duly sworn according to law, deposes and states that he is the Defendant in the matter of City of ______________ v. _________________ being case number ___________ in the ______________ Municipal Court of _________________ County, Ohio.

AFFIANT FURTHER STATES that;

1. I have reviewed the attached Affidavit of Disqualification and Memorandum In Support for _______________ Municipal Court Judge _______________________________ and;

2. The information is true and correct to the best of my knowledge, belief and recollection.

AFFIANT FURTHER SAYETH NAUGHT.

ATTESTATION

The above facts are true and correct to the best of my knowledge information and belief.

Signed by:

Name: _______________________

Street: _______________________

City: _______________ OH ZIP: _____

Phone: _____________________

SWORN TO BEFORE ME and subscribed in my presence this ____ day of _____________ , 20___.

________________________________

NOTARY PUBLIC