Ohio Department of Public Safety
Division of Homeland Security
http://www.homelandsecurity.ohio.gov
PUBLIC EMPLOYMENT
In accordance with section 2909.34 of the Ohio Revised Code
DECLARATION REGARDING MATERIAL ASSISTANCE/NONASSISTANCE TO A TERRORIST ORGANIZATION
This form serves as a declaration of the provision of material assistance to a terrorist organization or organization that supports terrorism as identified by the U.S. Department of State Terrorist Exclusion List (see the Ohio Homeland Security Division website for a reference copy of the Terrorist Exclusion List).
Any answer of “yes” to any question, or the failure to answer “no” to any question on this declaration shall serve as a disclosure that material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List has been provided. Failure to disclose the provision of material assistance to such an organization or knowingly making false statements regarding material assistance to such an organization is a felony of the fifth degree.
For the purposes of this declaration, “material support or resources” means currency, payment instruments, other financial securities, funds, transfer of funds, and financial services that are in excess of one hundred dollars, as well as communications, lodging, training, safe houses, false documentation or identification, communications equipment, facilities, weapons, lethal substances, explosives, personnel, transportation, and other physical assets, except medicine or religious materials.
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FIRST NAME |
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MIDDLE INITIAL |
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HOME PHONE |
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DECLARATION
In accordance with division (A)(2)(b) of section 2909.32 of the Ohio Revised Code
For each question, indicate either “yes,” or “no” in the space provided. Responses must be truthful to the best of your knowledge.
1.Are you a member of an organization on the U.S. Department of State Terrorist Exclusion List?
Yes
No
2.Have you used any position of prominence you have with any country to persuade others to support an organization on the U.S. Department of State Terrorist Exclusion List?
Yes
No
3.Have you knowingly solicited funds or other things of value for an organization on the U.S. Department of State Terrorist Exclusion List?
Yes
No