SUBSIDIARY DISCLOSURE FORM 1. WHO MUST COMPLETE THIS FORM. Any subsidiary, if the subsidiary, or an individual who serves as an officer, director, partner, or the equivalent of a key employee for the facilities of the subsidiary, is, or has been charged with, or has been convicted of a crime listed in Division B of Section 3734.44 of the Revised Code (see Appendix A), must complete this form. Also, any subsidiary that has been a defendant of a civil judicial complaint or adjudged liable for a violation of an environmental protection law resulting in a penalty of fifty thousand dollars or more must complete this form. 2. WHO IS A SUBSIDIARY. For purposes of filing a subsidiary disclosure statement form, "subsidiary" means a business concern which is owned or controlled by: a) a business concern referred to in paragraph (B)(2)(b) of Rule 109:6-1-02 of the Ohio Administrative Code (O.A.C.). (Each business concern which is a partner of the applicant or permittee, and each business concern which owns or controls the applicant or permittee); b) an individual who owns or controls the applicant or permittee or prospective owner; or c) the applicant or permittee or prospective owner. 3. ALL QUESTIONS MUST BE ANSWERED. Read every question carefully before answering any. Answer every question completely. Do not leave any blank spaces. If a question does not apply to you, enter "Not applicable" or "N/A" in the space provided for an answer. If there is nothing to disclose in answer to a particular question, enter "None" in the space provided for an answer. 4. ANSWER COMPLETELY AND TRUTHFULLY. Failure to answer any questions completely may result in your statement being returned to you for supplementation of your answers. If the answer to a question in this form is identical to an answer given to a previous question in the form, you may answer the later question by writing "Same as ____." For example, if the answer to Question 3 is the same as the answer to Question 2, you may answer Question 3 by writing "Same as 2." WARNING: FRAUDULENT, DECEPTIVE OR MISLEADING ANSWERS MAY RESULT IN THE DENIAL OR REVOCATION OF THE APPLICANT'S OR PERMITTEE'S LICENSE. IN ADDITION, ANY PERSON WHO KNOWINGLY OR RECKLESSLY MAKES FALSE OR MISLEADING STATEMENTS ON THIS FORM MAY BE SUBJECT TO CRIMINAL PROSECUTION. Be especially careful not to leave out information in a way that might create an impression that you are trying to hide it. For example, a minor criminal conviction will probably not disqualify your firm from being licensed but attempting to conceal the conviction may lead to a finding of untrustworthiness, and result in disqualification. Omitting such information from this form, even unintentionally, may result in your trustworthiness being questioned. Even if the question is resolved in your favor, your application may be delayed while the inquiry goes forward. i American LegalNet, Inc. www.FormsWorkflow.com If you are unsure of, or do not remember the answer to a question, indicate this in some way - for example, by writing "Do not remember." This may result in additional inquiries from the Director of the Ohio EPA or the Attorney General's Office, but it will avoid the implication that you are trying to conceal information. However, you should not answer "Do not remember," or with similar words, simply because the information may not be immediately at hand. You are expected to make reasonable efforts to check your records so that you can answer the questions completely. 5. ADDITIONAL SPACE. If you need additional space to answer a question, use plain 8 1/2" x 11" paper. Insert additional pages immediately following the page on which the question you are answering appears. Be sure to indicate that your answer to the question is "continued on next page," and indicate on the additional page which question is being continued there. When you have finished answering all questions, and have attached all additional pages, consecutively number each page at the top right corner - including the additional pages. Pages of the original form which need to be renumbered as a result of adding pages should be renumbered at the space provided after "Your Page No.__" 6. TYPE OR PRINT YOUR ANSWERS. Type or print in legible block letter style. Handwritten forms will be returned if entries are in script or are unreadable. DO NOT USE A SCRIPT TYPEFACE. 7. INTERPRETIVE ASSISTANCE IN COMPLETING DISCLOSURE STATEMENTS. If an applicant, permittee, or prospective owner needs interpretive assistance in completing a disclosure statement, it may submit in writing to the Attorney General a regulatory guidance request seeking an informal, nonbinding interpretation of a regulatory requirement imposed by Sections 3734.40 to 3734.47 of the Revised Code and the rules adopted thereunder. a. The submission of a regulatory guidance request shall in no way alter the obligation of an applicant, permittee or prospective owner to fully comply with all requirements imposed by Sections 3734.40 to 3734.47 of the Revised Code and the rules adopted thereunder. b. There is no obligation upon the Attorney General to respond to a regulatory guidance request other than as the Attorney General determines in his or her sole discretion based upon available human resources and the need to employ those resources to perform the mandatory obligations imposed by Sections 3734.40 to 3734.47 of the Revised Code and the rules adopted thereunder. c. The response provided by the Attorney General to any regulatory guidance request shall be used by the applicant, permittee, or prospective owner solely as a guidance to assist in the preparation of a disclosure statement. The response of the Attorney General shall not be binding upon anyone, including, but not limited to, the applicant, permittee or prospective owner, the Attorney General, the Director of Environmental Protection, a local ii American LegalNet, Inc. www.FormsWorkflow.com board of health, or the Hazardous Waste Facility Board. The response may be accorded such deference as is usually provided to the administrative interpretation of a statutory requirement. IF YOU HAVE GENERAL NON-INTERPRETIVE QUESTIONS ABOUT HOW TO FILL OUT THIS FORM, CALL THE ATTORNEY GENERAL’S OFFICE AT (614) 466-3843 8. The information required to be submitted in the disclosure statement pursuant to Rule 109:6-1-02 of the O.A.C. is intended to be the information necessary to begin the background investigation required by Sections 3734.40 through 3734.47 of the Revised Code. In limiting the scope of information required to be included in the disclosure statement, it is expressly contemplated that in individual investigations the Attorney General may have reasonable cause to believe that the procedures contained in Section 3734.43 of the Revised Code should be employed to review additional information. Nothing contained in Rule 109:6-1-02 of the O.A.C. shall be construed to restrict or limit the scope of information the Attorney General may seek pursuant to the procedures established in Section 3734.43 of the Revised Code. iii American LegalNet, Inc. www.FormsWorkflow.com Page No. 1 Your Page No. SUBSIDIARY DISCLOSURE STATEMENT NAME OF APPLICANT, PERMITTEE, OR PROSPECTIVE OWNER: NAME OF PERSON TO BE CONTACTED REGARDING THESE FORMS: Name Title CONTACT PERSON'S TELEPHONE NUMBER: ( 1. ) NAME OF SUBSIDIARY COMPLETING THIS FORM. State the complete name of the subsidiary as it appears on the certificate of incorporation, charter, by-laws, partnership agreement or other official document, which establishes the name of the business concern. (If no such document exists, state the name the business uses.): TELEPHONE NUMBER: ( ) FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): ADDRESS OF PRINCIPAL OFFICE: (Number and Street) (City) (State) (Zip Code) American LegalNet, Inc. www.FormsWorkflow.com Page No. 2 Your Page No.___ CIVIL LITIGATION AND CRIMINAL PROCEEDINGS. 2. CIVIL SUITS. For each civil judicial complaint filed against or judgment of liability of the subsidiary for violation of an environmental protection law resulting in a penalty of fifty thousand dollars or more, state or provide: Case Name Date Filed Docket Number Name & Location of Presiding Court (Optional) Provide any explanation of the action or alleged violation which you may choose to submit (Identify which action by Caption/Title and Docket Number). 3. CRIMINAL CHARGES AND INDICTMENTS OF SUBSIDIARIES. For any criminal charge or indictment filed against the subsidiary for a crime listed in Division (B) of Section 3734.44 of the Revised Code (See Appendix A) state or provide: Crime Charged Date Filed Indictment, Information or Complaint Number Name & Location of Presiding Court (Note) List all applicable charges or indictments - even if they are arguably not disqualifying. Provide any explanation of the prosecution you may choose to submit. (Identify prosecution by indictment number.) American LegalNet, Inc. www.FormsWorkflow.com Page No. 3 Your No.____ 4. CRIMINAL CHARGES AND INDICTMENTS OF INDIVIDUALS. For any criminal charge or indictment filed against an individual, who serves as an officer, director, partner, or the equivalent of a key employee for the facilities of the subsidiary, for a crime listed in Division (B) of Section 3734.44 of the Ohio Revised Code (see Appendix A), state or provide: Name of Individual Crime Charged Date Filed Indictment, Information or Complaint Number Name & Location of Presiding Court (Note) List all applicable charges or indictments - even if they are arguably not disqualifying. 5. CRIMINAL CONVICTIONS OF SUBSIDIARIES. For any criminal conviction of the subsidiary for a crime listed in Division (B) of Section 3734.44 of the Ohio Revised Code (See Appendix A), state or provide: Crime of Which Convicted Date Filed Indictment, Information or Complaint Number Name & Location of Presiding Court (Note) List all applicable charges or indictments - even if they are arguably not disqualifying. American LegalNet, Inc. www.FormsWorkflow.com Page No. 4 Your Page No._____ 6. CRIMINAL CONVICTIONS OF INDIVIDUALS. For any criminal conviction, for a crime listed in Division (B) of Section 3734.44 of the Ohio Revised Code (see Appendix A), of an individual who serves as an officer, director, partner, or the equivalent of a key employee for the facilities of the subsidiary, state or provide: Name of Individual Crime of Which Charged Date Filed Indictment, Information or Complaint Number Name & Location of Presiding Court (Note) List all applicable convictions - even if they are arguably not disqualifying. Provide any explanation of the prosecution you may choose to submit. (Identify prosecution by indictment number.) American LegalNet, Inc. www.FormsWorkflow.com Page No. 5 Your Page No._____ AFFIDAVIT STATE OF ) ) ) COUNTY OF I, _________________________________________, do hereby swear (or affirm) that I am (Name) authorized and able to supply the information in this Subsidiary Disclosure Form and that such information about the business concern given in answer to Questions (Please circle the Questions to which this affidavit applies) 1 2 3 4 5 6 is true and accurate to the best of my knowledge. I am aware that if any of the foregoing statement made by me is knowingly false, I am subject to criminal prosecution or civil action. Date: (Signature) (Type or Print Name Here) (Title or Position) If a person other than the individual signing this affidavit (e.g., accountant or attorney) prepared form, indicate that person's name, address and telephone number: Sworn to and subscribed before me this _________ day of _____________________________, 20___________. _________________________________________________ Notary Public Seal or authority of Notary Public *Sufficient affidavits should be attached such that some person swears to the truth and accuracy of the American LegalNet, Inc. www.FormsWorkflow.com Page No. 6 Your Page No._____ APPENDIX A Pursuant to Paragraph (B) of Section 3734.44 of the Revised Code, an applicant or licensee may be disqualified from holding a solid, infectious, or hazardous waste license if any individual or business concern required to be listed in the disclosure statement, or shown to have a beneficial interest in the business of the applicant or the permittee, has been convicted of any of 21 categories of crimes listed in the statute. Disqualifying crimes are any of the following under Ohio laws, or equivalent laws of any other jurisdiction: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Murder, Kidnapping, Gambling, Robbery, Bribery, Extortion, Criminal Usury, Arson, Burglary, Theft and related crimes, Forgery and fraudulent practices, Fraud in the offering, sale or purchase of securities, Alteration of motor vehicle identification numbers, Unlawful manufacture, purchase, use or transfer of firearms, Unlawful possession or use of destructive devices or explosives, Violation of Sections 2925.03, 2925.11, 2925.32 or 2925.37 or Chapter 3719 of the Revised Code, except possession of less than one hundred grams of marijuana, or unless the amount of marijuana resin, or extraction or preparation of such resin is less than five grams, and the amount of such resin in a liquid concentrate, liquid extract, or liquid distillate form is less than one gram; Corrupt activities under Sections 2923.31 to 2923.36 of the Revised Code, Violation of criminal provisions of Chapter 1331 of the Revised Code, Any violations of the criminal provisions of any federal or state environmental protection laws, rules, or regulations that is committed knowingly or recklessly as those terms are defined in Section 2901.22 of the Revised Code; Violation of Chapter 2909 of the Revised Code; and Any offense specified in Chapter 2921 of the Revised Code. 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