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Personal History Disclosure Affidavit And Information Release Authorizations - Ohio

Personal History Disclosure Affidavit And Information Release Authorizations Form. This is a Ohio form and can be used in Citizen Protection Attorney General Office Statewide .
 Fillable pdf Last Modified 3/21/2011
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PERSONAL HISTORY DISCLOSURE AFFIDAVIT AND INFORMATION RELEASE AUTHORIZATIONS I, ______________________________________ have previously filed a Personal History Disclosure Form (PHDF) on _________________________ with the Ohio Attorney General's Environmental Background Investigation Unit (EBIU) relating to the ________________________________________ Applicant Business Concern and, if applicable, _______________________ Non-Applicant Business Concern. 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: ____________________________________________________________________________________ ____________________________________________________________________________________ To all Courts, Probation Departments, Selective Service Boards, Credit Bureaus, Employers, Educational Institutions, Banks, Financial and Other Such Institutions, and all Governmental Agencies (federal, state and local without exception both foreign and domestic), I have authorized the Attorney General of Ohio to conduct an investigation into my background. Therefore, you are hereby authorized to release any and all information pertaining to me, documentary or otherwise, as requested by an appropriate employee, agent or representative of the Attorney General. This authorization shall supersede and countermand any prior request or authorization to the contrary. A copy of this authorization will be considered as effective and valid as the original. I hereby certify that I have given the Ohio Attorney General permission to obtain a copy of any arrest or conviction record pertaining to me now available to the Ohio Bureau of Criminal Identification and Investigation (BCI&I). I hereby release BCI&I and all individuals connected therewith from all liability in connection with the proper dissemination of such arrest and conviction data. _______________________________________ Name _______________________________________ Home Address (Number and Street) _______________________________________ City, State and Zip Code _______________________________________ Signature _______________________________________ Social Security Number _______________________________________ Date of Birth _______________________________________ County of Residence ____________________________ Date Sworn to and subscribed before me this _____ day of ____________________________, 20__. __________________________________________ 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. Please be advised: Individuals completing this form are not required to include changes to information disclosed in previous Personal History Disclosure Forms if that information is no longer required to be disclosed in the current Personal History Disclosure Form. American LegalNet, Inc. www.FormsWorkFlow.com
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