PERSONAL HISTORY AFFIDAVIT STATE OF _________________________: COUNTY OF _________________________: ______________________________________, being first duly cautioned and sworn, deposes and states as follows: I have previously filed a Personal History Disclosure Form on ______________________________, with the Ohio Attorney General’s Environmental Background Investigation Unit (EBIU) relating to the _________________________________________________________ facility located at _____________________________________________ in ____________________________, Ohio. I, ______________________________________, hereby swear or affirm under the penalties of perjury and falsification that there are no changes to my Personal History Disclosure Form except through previously filed Affidavits or as follows: __________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Dated this _____ day of ____________________________, 200__. Signature__________________________________ Sworn to and subscribed before me this _____ day of ____________________________, 200__. __________________________________________ NOTARY PUBLIC My Commission Expires:_____________________ Under Ohio Revised Code 2921.11 and 2929.11, perjury is a felony of the third degree; punishable by imprisonment for one to ten years and a fine up to $5,000. Under Ohio Revised Code 2921.13 and 2929.21, falsification is a misdemeanor of the first degree; punishable by imprisonment for six months and a fine up to $1,000. American LegalNet, Inc. www.FormsWorkflow.com