State Retirement Board Fiduciary Complaint Form Section 109.98 of the Ohio Revised Code establishes authority for the Attorney General to maintain a civil action for breach of fiduciary duty by a member of a state retirement board, including and limited to the public employees retirement board, board of trustees of the Ohio police and fire pension fund, school employees retirement board, state teachers retirement board, and state highway patrol retirement board. The Charitable Law Section processes complaints alleging violations of this section of law. Complaint information may be sent to the Attorney General at the address listed above. Your Name________________________________________________ Today's Date ____________________ Last First MI Address __________________________________________________________________________________ City ___________________________ State_____ Zip Code___________ County _______________________ Home Phone ________________ Work Phone ________________ email _______________________ State Retirement Board Information Name of State Retirement Board_______________________________________________________ State Retirement Board Individual(s) of concern Name _______________________________________ Title _________________________________ Last, First, MI (List others in description section) Address __________________________________________________________________________________ City ___________________________ State_____ Zip Code___________ County _______________________ Phone ________________ Other ________________________________________________________ Have you reported this matter to any other investigative agencies? Yes No If yes, please provide the name of the agency and the contact person with that agency. American LegalNet, Inc. www.FormsWorkFlow.com Description of Violation Please explain your complaint in as much detail as possible. You may use additional sheets if necessary. Please print or type clearly. Try to be brief, but be sure to tell WHAT happened, WHO was involved, WHEN and WHERE it happened. Be specific about any verbal statements that were made to you. Describe events in the order in which they happened. Attach COPIES of all letters, documentation, and other papers that relate to your complaint, and keep the originals. PLEASE NOTE: This complaint form, as well as all documents you send us, are public records subject to Ohio's Public Records Act. This law requires all public records to be available for inspection by anyone, upon request. The information contained in this complaint is true and accurate to the best of my knowledge, information, and belief. Today's Date ________________ Your Signature ________________________________________ Office Use Only Staff: Complaint Number: American LegalNet, Inc. www.FormsWorkFlow.com