AFFIDAVIT IN COMPLIANCE WITH SECTION 3517.13
OF THE OHIO REVISED CODE
STATE OF OHIO
COUNTY OF
SS:
Personally appeared before me the undersigned, as an individual or as a representative of
for a contract for
(Name of Entity) (Type of Product or Service)
to be let by the County of Allen, who, being duly cautioned and sworn, makes the following statement
with respect to prohibited activities constituting a conflict of interest or other violations under Ohio
Revised Code Section 3517.13, and further states that the undersigned has the authority to make the
following representation on behalf of himself or herself or of the business entity:
1. That none of the following has individually made after April 4, 2007, and that, if awarded a contract
for the purchase of goods or services with a cost aggregating more than $10,000 in a calendar year,
none of the following individually will make, beginning on the date the contract is awarded and
extending until one year following the conclusion of the contract, as an individual, one or more
campaign contributions totaling in excess of $1,000, to any member of the Allen County Board of
Commissioners or their individual campaign committees:
a. myself;
b. any partner or owner or shareholder of the partnership (if applicable);
c. any owner of more than 20% of the corporation or business trust (if applicable);
d. each spouse of any person identified in (a) through (c) of this section;
e. each child seven years of age to seventeen years of age of any person identified in divisions (a)
through (c) of this section (only applicable to contributions made on or after January 1, 2007).
2. That none of the following have collectively made after April 4, 2007, and that, if awarded a contract
for the purchase of goods or services with a cost aggregating more than $10,000, in a calendar year,
none of the following collectively will make, beginning on the date the contract is awarded and
extending until one year following the conclusion of the contract, one or more campaign contributions
totaling in excess of $2,000, to any member of the Allen County Board of Commissioners or their
individual campaign committees:
a. myself;
b. any partner or owner or shareholder of the partnership (if applicable);
c. any owner of more than 20% of the corporation or business trust (if applicable);
d. each spouse of any person identified in (a) through (c) of this section;
e. each child seven years of age to seventeen years of age of any person identified in divisions (a)
through (c) of this section.
f. any political action committee affiliated with any person identified in divisions (a) through (c)
of this section.
Signature:
Title:
