1-AuditorsForm

REQUEST FOR REDACTION OF INFORMATION ON A LAW ENFORCEMENT OFFICER IN ACCORDANCE WITH
O.R.C. 149.43 (A)(7)

State of Ohio
County of: ___________________________________

I ____________________________________________, of lawful age, upon oath state:
   (print name)
I am a law enforcement officer employed by _________________________________________________,
                                                                        (name of employer)
located at ______________________________________________, _____________________________,
                       (address of employer)                                                                                                (city)
Ohio ______________.
         (zip code)

All records in your custody and control and containing the following information may be excluded from the public record
in accordance with O.R.C. 149.43(A)(7), and I hereby request that you redact my residential and familial information
from these records when responding to any request for records that you may receive in the course and scope of your
duties as follows:

       1. The address of my personal residence listed below.
       2. My social security number, residential telephone number, bank account, debit card, charge card, or credit card
            number, and emergency telephone number.
       3. My medical information.
       4. The name, the residential address, the name of the employer, the address if the employer, the social security
            number, the residential telephone number, and bank account, debit card, charge card, or credit card number, or
            the emergency telephone number of my spouse, former spouse, and child as listed on the back of this form.

Dated: __________________, 2007                   _______________________________________
                                                                             (signature of affiant)

                                                                                                     _______________________________________
                                                                             (street address)

                                                                                                     ____________________________________________________
                                                                                                       (city, state and zip code)

Subscribed and sworn before me this _________ day of _____________, 2007.

                                                                              _______________________________________
                                                                                 (signature and seal of notary public)

                                                                              My commission expires: _____________________