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EXHIBIT A
Case: 1:25-cv-00481-DRC-KLL Doc #: 4-2 Filed: 08/08/25 Page: 2 of 26 PAGEID #: 240
                   Plaintiff,
 vs.
CLERMONT COUNTY,OHIO ET AL
                   Defendant.
                                      /
                   STATE of FLORIDA                  )
                                                     )ss
                   COUNTY of BROWARD.                )
         Now comes Plaintiff BERT DAMIAN LEWIS, and having personal knowledge of the
 facts contained herein, does hereby state the following:
 1) I am the Plaintiff in the above-captioned civil rights action and submit this declaration
       in support of my Motion for a Temporary Restraining Order and Preliminary
       Injunction, as well as the accompanying Memorandum ofLaw.
 2) The statements set forth herein are based upon my personal knowledge and are true and
       correct to the best of my knowledge. They arc supported by documents and records that I
       personally created, obtained, or submitted, and which are included as Exhibits to this filing.
 3) On March 14, 2020, my vehicle was involved in a motor vehicle collision on Amelia-
       Olive Branch Road in Clermont County, Ohio lExhibit Al], At no point before, during,
       or after the incident was any person, myself included, placed under arrest, detained, or
       advised that they were under arrest [Exhibit A2]. Clermont County Sheriffs Deputy
       Michael J. Ross responded to the scene and was the officer responsible for
       documenting the incident [Exhibit Al].
                                                 Page 1 of 12
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 4) Notwithstanding the absence of any arrest or detention at the scene or at the hospital,
    Deputy Ross later submitted a BMV Form 2255 [Exhibit A3], in which he certified
    under penalty of perjury that 1 had been arrested for operating a vehicle under the
    influence (OVI). This certification is factually inaccurate. Official records maintained
    by both Clermont County [Exhibit A2] and the State of Ohio [Exhibit A4] indicate
    that no chemical tests were conducted, no field sobriety tests were administered, and no
    individual involved in the March 14, 2020 incident was arrested based on probable
    cause, either at the scene [Exhibit Al] or thereafter.
    routed to Stephanie Ross, the ChiefAdministrator for the Grand Jury and Felony Intake
    Division, who is also the spouse of Deputy Michael J. Ross. Mrs. Ross did not disclose
    her marital relationship with Deputy Ross at any point during the proceedings [Exhibit
    B2]. Despite the obvious and disqualifying conflict of interest, she continued to
    supervise the operations of the Grand Jury and Felony Intake Division [Exhibit B3],
    which ultimately retumed an indictment against me approximately four months after I
    filed my misconduct complaint conceming her husband [Exhibit B4].
 6) A digital forensic analysis has revealed that the secure email accounts assigned to
    Deputy Michael J. Ross by the Clermont County Sheriff's Office [Exhibit Cl], as well
    as the secure administrative email account of the Clermont County Prosecutor's Office
    assigned to his spouse, Stephanie Ross [Exhibit C2], were accessed over an extended
    period of time by the same electronic device [Exhibit C3]. The preponderance of
    forensic evidence identifies the device as Deputy Ross's personal iPhone [Exhibit C3].
    This device has been used to access, and in certain instances intercept, privileged legal
    communications and case-related materials, including emails containing evidentiary
    documents and legal filings that directly implicate Deputy Ross in acts of perjury and
    other forms of official misconduct [Exhibit C4].
                                            Page 2 of 12
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        7) Read-receipt logs [Exhibit C5| and corresponding timestamp metadata reflect repeated
           instances of identical-second collisions between two distinct Clermont County
           government email accounts [Exhibit €6]. These timestamp collisions constitute
           conclusive digital evidence of unauthorized surveillance originating from the secure
           email account assigned to Deputy Michael J. Ross [Exhibit C?]. The targets of this
           covert surveillance included attorney-client communications, protected attorney work
           product, and whistleblower correspondence. Forensic examination further confirms
           that this unauthorized access took place both prior to and following my issuance of a
           formal spoliation notice on June 11, 2025 [Exhibit C7].
        8) As detailed in my Verified Petition for Writ of Prohibition [Exhibit Dl] and supporting
           materiais, 1 am currently facing six felony charges in the matter of State v. Lewis, Case
           No. 2025 CR 000360. These charges are predicated upon the demonstrably false
           statements made by Deputy Michael J. Ross on March 14, 2020 [Exhibit D2].
        9) The feiony charges referenced above were filed under seal on June 12, 2025 [Exhibit
           D31, precisely one day after I served a formal Notice of Intent to Litigate under 42
           U.S.C. § 1983 upon officials within the Clermont County Prosecutor's Office [Exhibit
           D4j. That notice identified multiple constitutional violations, including Brady
           violations, deprivation of civil rights, and malicious prosecution.
        10)On June 30 and July 7, 2025, 1 submitted a total of twenty-seven pro se filings to the
           Clermont County Court of Common Pleas. Of these, twenty were either refused
           docketing or obstructed by court personnel acting under the administrative authority of
           Stephanie Ross [Exhibit DSf The suppressed filings included a Motion to Recuse
           Prosecutor Mark J. Tekulve, Stephanie Ross's employer [Exhibit D8|, and a Motion
           for Judicial Notice [Exhibit D91 addressing the underlying perjury committed by her
           spouse. Deputy Michael J. Ross [Exhibit B21. On July 7, after submitting additional
           documents via facsimile [Exhibit DIO], I received a voicemaii from the Cierk's Office
           instructing me to "stop faxing" filings, and stating that "your entry has been denied"
           [Exhibit Dll]. No legal explanation for this denial was provided, nor has one been
           issued to date.
                                                   Page 3 of 12
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 11)Public marriage records confirm the spousal relationship between Michael J. Ross and
    Stephanie Ross [Exhibit B2]. Nevertheless, despite the conflict of interest posed by my
    misconduct complaint against Deputy Ross [Exhibit Bli, Stephanie Ross continued to
    exercise administrative authority over the Grand Jury and Felony Intake Division [Exhibit
    B3], which later returned an indictment charging me with six felonies [Exhibit B4].
 12)As a result, I now face not only an unlawful and retaliatory prosecution but also a
    credible, imminent threat of physical harm should I be remanded into the custody of
    officials whom I have directly accused of peijury, evidence tampering, and
    constitutional violations [Exhibit El). This threat is substantiated by authenticated
    evidence of ongoing unlawful surveillance [Exhibit E2], falsified reports [Exhibit
    A31, and coordinated retaliatory acts [Exhibit E31. A recently updated digital
    surveillance report prepared in response to breaches in my device's network security
    [Exhibit C7] confirms that both my electronic activity and physical location continue
    to be covertly monitored, despite the prior revocation of authorized access and the
    implementation of advanced firewall protections.
 13)The digital surveillance infrastructure targeting my communications remains active and
    presents an ongoing risk of irreparable harm. Specifically, a NordVPN tunnel has been
    identified as routing data traffic through an Amazon Web Services (AWS)EC2 node
    via port 8884. This configuration enables the interception of confidential
    communications, including legal filings and privileged correspondence. The
    persistence and operational capacity of this surveillance mechanism justifies the
    issuance of immediate injunctive relief to prevent further violations of my
    constitutional and statutory rights [Exhibit C7].
 14)The imminent threat to my physical safety arises directly from the unauthorized and
    covert monitoring of both my digital communications and real-time physical location.
    As detailed in the most recent forensic surveillance report [Exhibit C7], unauthorized
    access points continue to route my device activity through a NordVPN-AWS EC2 node
    on port 8884. This setup enables both the interception of protected communications
    and real-time geolocation tracking. The exposure of this sensitive data to individuals I
                                            Page 4 of 12
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    have formally accused of perjury, unlawful surveillance, and other serious misconduct
    [Exhibit D4; Exhibit E4] has created a well-founded and continuing fear for my
    personal safety and has substantially undermined my ability to secure my person and
    property against retaliatory harm.
 15)The retaliatory character of the prosecution and the misuse of investigative powers are
    further confirmed by formal notices I received from Google [Exhibit E5[ and
    Facebook [Exhibit E6[ regarding the execution of search warrants targeting my digital
    accounts. On February 27, 2025, Google confirmed receipt of a search warrant issued
    by the Clermont County Sheriff's Office for access to my account, based on a legal
    process initiated just two days earlier on February 25, 2025. Similarly, on March 3,
    2025, Facebook informed me of a legal request from law enforcement to access my
    Facebook account. These investigative actions were undertaken mere weeks after I
    filed my misconduct complaint against Deputy Michael J. Ross on February 11, 2025
    [Exhibit Bl], following five years of complete prosecutorial inaction regarding the
    March 14,2020 incident [Exhibit E7]. Upon information and belief, the foundation for
    these invasive warrants was Deputy Ross's peijured BMV Form 2255 [Exhibit A3[, a
    document already established to be false and contradicted by multiple official records
    [Exhibits Al, A2]. The timing, scope, and falsified basis of these digital surveillance
    efforts clearly indicate a retaliatory misuse of law enforcement tools and constitute a
    serious abuse of investigatory authority for improper purposes [Exhibits E9,ElOj.
 16)Public sources consistently identify Deputy Michael J. Ross as a central figure in
    digital investigations and surveillance operations throughout Clermont County, Ohio
    [Exhibit Ell]. Media reports from March 2024 [Exhibit Ell] confirm that Deputy
    Ross has collaborated with federal agencies including the FBI and Secret Service on
    regional cybercrime matters, reflecting access to and familiarity with advanced
    surveillance technologies. Public statements issued by the Clermont County Sheriff's
    Office in both June 2023 and June 2025 [Exhibit E14] further document Deputy
    Ross's role in leading digital safety and situational awareness training sessions,
    indicating his operational engagement in digital monitoring practices. In a statement
                                          Page 5 of 12
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    dated December 27, 2024, Prosecutor Mark J. Tekulve publicly praised Deputy Ross's
    ability to extract and retrieve video files from digital devices, skills emblematic of
    someone capable of executing unauthorized, targeted surveillance.
 17)The prosecutorial process in this matter has been fundamentally compromised by
    demonstrable conflicts of interest, breaches of confidentiality, and unlawful
    surveillance [Exhibit C4]. These defects have irreparably undermined the adversarial
    structure required for a legitimate prosecution. Given the pervasive nature of these
    violations, no adequate remedy at law exists to restore the impartiality or integrity of
    the charging process or to protect the confidentiality of ongoing legal correspondence
    [Exhibit C7]. Judicial intervention is therefore necessary to preserve due process.
 18)The digital forensic evidence presented here has been validated through methodologies
    consistent with standards promulgated by the National Institute of Standards and
    Technology (NIST) and corroborated by peer-reviewed protocols [Exhibit El6]. When
    considered in conjunction with the documented history of misconduct by Clermont
    County officials [Exhibit Fl], this evidence establishes a strong likelihood of success on
    the merits of my civil rights claims under 42 U.S.C. § 1983. Additionally, the procedural
    deficiencies underlying the charging process, including the reliance on a falsified BMV
    Form 2255 [Exhibit AS] and the complete absence ofany lawful predicate for indictment
    [Exhibit Al],further support my entitlement to injunctive relief.
 19)The issuance of a temporary restraining order and preliminary injunction in this matter
    serves the public interest by reinforcing the constitutional requirement that
    prosecutorial power be exercised lawfully and without retaliatory motive. Allowing the
    prosecution to proceed under the present circumstances, marked by documented
    surveillance abuse [Exhibit C71 and intentional obstruction of legal filings [Exhibit
    Dll], would not only prejudice the accused, but also degrade public confidence in the
    fairness and legitimacy of the criminal justice system. The balance of equities therefore
    strongly favors the requested relief.
 20)The sequence of events culminating in the present felony charges plainly illustrates a
    retaliatory motive and a profound breach of prosecutorial integrity [Exhibit FIJ. My
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    infringe upon my rights to due process and a fair trial, protection against unreasonable
    searches and seizures, and freedom from retaliation for engaging in constitutionally
    protected speech and petitioning for legal redress. The structural contamination of the
    adversarial process is profound, systemic, and incapable of correction without
    immediate and meaningful judicial intervention.
 22)The prosecution currently pending against me was initiated in bad faith and in direct
    retaliation for my protected whistleblower activity [Exhibit E3]. The charges are
    predicated on knowingly perjured evidence and lack any legitimate legal foundation.
                                            Page 7 of 12
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Notably, the indictment, sealed and filed on June 12, 2025 [Exhibit D2], was entered
           just one day after I served a formal notice of intent to pursue civil rights litigation
           imder 42 U.S.C. § 1983 [Exhibit D4[. The use of the falsified BMV Form 2255 as the
            basis for expansive surveillance warrants and felony charges, following a five-year
            period of complete investigative dormancy [Exhibit F71, provides compelling
           evidence of retaliatory motive and a breakdown in lawful prosecutorial function
           [Exhibit F8].
        23)Further underscoring the pattem of misconduct. Deputy Ross has a prior disciplinary
            history involving a documented Miranda violation in a 2003 triple homicide investigation
           [Exhibit F91. In that case, Ross continued interrogation after the suspect invoked the
           right to counsel, resulting in suppression of a confession and nearly voiding the
           conviction. This history was known to the Clermont County Prosecutor's Office [Exhibit
           FIO] and iibstrates a recurring disregard for constitutional protections, now reemerging
           in the form ofretaliatory action and concealment through the current prosecution.
        24)The evidentiary record fails to establish any ofthe elements required to support the charged
           offenses. There is no admissible evidence identifying me as the operator of the vehicle
           involved in the March 14, 2020 incident [Exhibit Glf The other party involved did not
           sustain any serious injury [Exhibit G2], and in June 2020, voluntarily executed a fiill
           release of all claims arising from the incident [Exhibit G3]. Public records show that the
            State lacks any evidence of impairment, operation, or reckless driving necessary to support
           charges under Ohio's OVI statute or related traffic offenses [Exhibits Al,A4,G41.
        25)The charge of drug possession is equally unsupported by the facts and law. I possess a
            valid, ongoing prescription from my primary care physician for the medication in
            question [Exhibit G51, and I submitted a complete four-year prescription history to the
            appropriate authorities in February 2025 [Exhibit G61. This documentation establishes
            a full affirmative defense under Ohio law. Consequently, the possession charge, as well
            as the derivative paraphemalia charge, are both legally deficient and unsustainable.
        26)The administrative license suspension ("ALS") issued against me [Exhibit G7[ is
            procedurally and substantively invalid for two independent reasons. First, as
                                                    Page 8 of 12
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     established by official records, no arrest was ever made in connection with the March
     14, 2020 incident that could legally support an ALS under Ohio Revised Code §
     4511.191 [Exhibit A2]. Second, the ALS was submitted to the Ohio Bureau of Motor
     Vehicles nine days after the statutorily prescribed deadline, rendering the suspension
     procedurally defective and unenforceable under Ohio law [Exhibit G8].
  27)Despite the absence of any incriminating evidence in public records [Exhibits A1-A4],
     the existence of a complete and documented legal defense [Exhibits G5-G6], and the
     presence of fatal procedural defects, both the prosecution and the court have allowed
     these unfounded charges and the invalid ALS to remain pending for over five months
     [Exhibit G9]. This continued prosecution defies the State's clear legal obligation to
     dismiss baseless charges and invalid administrative actions [Exhibit GIO].
  28)The court and prosecutorial authorities have not only failed to discharge their duty
     under applicable legal standards but have continued to unlawfully maintain
     proceedings against me despite irrefutable evidence showing: (a) no lawful basis for
     the charges exists in the public record [Exhibits A1-A4J; (b) an affirmative legal
     defense has been established [Exhibit G5]; and (c) critical procedural defects render
     both the charges and ALS legally void [Exhibit A3[. The persistence of these charges
     without evidentiary support constitutes a continuing violation of my rights and a failure
     of prosecutorial and judicial responsibility [Exhibits G9,GlOj.
  29)In addition to the aforementioned retaliatory actions, I have been subjected to ongoing
     harassment in the form of repeated calls from unidentified numbers [Exhibit H4].
     These calls consistently result in silent voicemails [Exhibit H5], often lasting between
     10 and 30 seconds. On July 25, 2025, I received a particularly disturbing 114-second
     voicemail containing no discernible speech but exhibiting extremely low signal energy
     throughout [Exhibit H6[. The acoustic profile consisted of ambient noise with no
     identifiable speech patterns, punctuated only by isolated spikes consistent with
     handling noise. The intentional silence and duration of the message are consistent with
     deliberate psychological intimidation and form part of a broader pattern of non-verbal
     harassment.
                                            Page 9 of 12
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           30)Most egregiously, and in clear violation of the boundaries of lawful law enforcement
              conduct, I have learned that on no fewer than four separate occasions [Exhibit H7],
              following my formal misconduct complaints against Deputy Michael J. Ross on February
               11 and 13, 2025 [Exhibit H8[, deputy sheriffs, including Deputy Ross himself, have
              appeared at the home of my 66-year-old widowed and disabled mother. These visits were
              unaccompanied by any lawful process or articulable law enforcement purpose. Given
              their timing and context, these actions appear intended to intimidate and harass me
              through proxy retaliation, targeting a vulnerable family member in an effort to cause
              emotional distress and deter me from seeking legal redress [Exhibit H9).
          31)Prior to the filing of my misconduct complaints, no law enforcement officer had ever
              appeared at my mother's residence in connection with any matter involving me.
              However, just six days after I formally reported Deputy Michael J. Ross for
              misconduct, he and several deputies arrived at her home in the middle of the night
              [Exhibit H10[, falsely claiming they were "looking for me." This intrusion occurred
              despite the Clermont County Prosecutor's Office possessing direct, contemporaneous
              knowledge that I was residing in Florida and had not lived in Ohio since 2003.
           32)In July 2025, following a dispute with the State regarding its refusal to disclose
              exculpatory evidence [Exhibit H12[, I issued a written and direct critique of Assistant
              Prosecutor Brian Shrive's unethical conduct during a contentious email exchange that
              also included Sheriff Chris Stratton. The very next day, Clermont County deputies again
              visited my mother's residence, where they aggressively coerced her into permitting a
              search of her home. According to her subsequent account, the deputies subjected her to
              public intimidation and humiliation, leaving her frightened and emotionally distressed.
              Despite my having communicated directly with Sheriff Stratton the night before,
              explicitly confirming my residence in South Florida, deputies returned just after
              midnight, forcefully knocking on her door until she broke down in uncontrollable sobs.
           33)On the day following the midnight visit, I sent an email to Sheriff Stratton and Assistant
              Prosecutor Shrive, denouncing their actions as retaliatory and unconscionable. I stated
unequivocally that such conduct constituted a misuse of public resources and appeared
                                                     Page 10 of 12
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     intended not to advance any legitimate investigative objective, but rather to terrorize a
     66-year-old disabled widow as a means of applying psychological pressure on her son
     [£xhibit H16J. 1 then notified all 99 members of the Ohio House of Representatives and
     each member of the State Senate [Exhibit H17], emphasizing that such state-sponsored
  37)Because Defendants have not yet been formally served and I have simultaneously filed
     an application for in forma pauperis status, advance notice to opposing parties is not
     practicable. For the reasons set forth herein, immediate injunctive relief is necessary to
     prevent ongoing and irreparable harm pending service and judicial scheduling.
  38)Pursuant to 28 U.S.C. § 1746,1 declare under penalty of perjury that the foregoing is
     true and correct.
                                             Page 11 of 12
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6^AA
                                        Page 12 of 12
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                   Plaintiff,
  vs.
CLERMONT COUNTY,OHIO ET AL
                   Defendant.
                                      /
                   STATE of OHIO                   )
                                                   )ss
               COUNTY of CLERMONT                  )
          Now comes DESIREE A. MINTON, having personal knowledge of the facts stated
  herein, states as follows:
1. I am the mother of Bert Damian Lewis and reside at 769 Rue Center Ct #1,
                                                Page 1 of2
ecAft Case: 1:25-cv-00481-DRC-KLL Doc #: 4-2 Filed: 08/08/25 Page: 15 of 26 PAGEID #: 253
                 business in Florida and that any communications beyond mail service should be
                 directed to him there.
               Pursuant to 28 U.S.C. § 1746,1 declare under penalty of perjury that the foregoing
          is true and correct. Executed on July 27, 2025.
                 Dated: July 27,2025                           Respectfully submitted.
                                                               Desiree A.Minton
                                                                  desimalottb 1@aol.com
                                                               769 Rue Center Ct. #i
                                                                  Cincinnati, Ohio 45245
                                                               Telephone:(513)307-0207
                                                     Page 2 of2
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EXHIBIT Traffic Crash Report                                                                  •DENOTES MANDATORY FIELD FOR SUPPLEMENT REPORT                                   LOCAL REPORT NUMBER <
                    ROUTE NUMBER         PREFIX 1 - NORTH     LOCATION ROAD NAME                                                            ROAD TYPE            LATITUDE DECIMAL DEGREES
                                                                                                                                                                                                                 SUSPECTED
                                                2 - SOUTH                                                                                                                                                  3 - MINOR INJURY
                                                3-EAST
                                                                                                                                               RD                     39.079786
                                                                Amelia Olive Branch                                                                                                                              SUSPECTED
                                                4-WEST
                   ROUTE NUMBER
                                                                                                                                                                                                           4 - INJURY POSSIBLE
                                         PREFIX 1 - NORTH       REFERENCE ROAD NAME (ROAD. MILEPOST. HOUSE #)                               ROAD TYPE          LONGITUDE decimal dec.rees
                                                2 - SOUTH                                                                                                                                                  5 - PROPERTY DAMAGE
                                                3 - EAST                                                                                                              -84.224368
                                                                4262                                                                                                                                             ONLY
                                                4 - WEST
      REFERENCE POINT                  DIRECTION                    ROUTE TYPE                                      .ROAD TYPE                                                  INTERSECTION RELATED
                                     FROM REFERENCE
         1 - INTERSEaiON
                                           1 - NORTH      IR-INTERSTATE hOUTEn'P)                AL' ALLEY       ^' HW - HIGHWAY, RD ■ ROAD                  |~| WITHIN INTERSECTION OR ON APPROACH
     3 I 2 - MILE POST           ,       , 2 - SOUTH
                                                          US-FEOE^L US RO^
                                                                                                 AV-AVENUE         .LA-LANE               SO-SQUARE
         3 - HOUSE #
                                 I       I 3-EAST
                                           4 - WEST
                                                                                                 RL-,^OUL^ARD '         - P|«|JEPpST ST.-STREET              n WITHIN INTERCHANGE AREA                NUMBER OF APPROACHES
             DISTANCE                  DISTANCE
                                                                STATE ROUTE     '                ,Cfl-aRCLE      /ibv-OVAL                TE-TERRACE
              REFERENCE              UNIT OF MEASURE
                                                          CR - ^JUMBERED COUNTY|ROUTE            CXf COURT        -.PK-.PJWKWAY           U-TRAIL.                                       ROADWAY
                                           1 - MILES                                             DB-DRIVE         .?Pl.-.PtlCE   .       ■ .WA-lWAY
                                           2-FEET         TRi- NUMBERED TOWNSHIP                 HE-heights      , ;PL-: PLACE       '                       □ ROADWAY DIVIDED
                                           3 - YARDS           ROUTE
                   LOCATION OF FIRST HARMFUL EVENT                                              MANNER OF CRASH COLUSION/IMPACT                          DIRECTION OF TRAVEL                        MEDIAN TYPE
               1 -ON ROADWAY                 9 - CROSSOVER                                    1 - NOT COLLISION 4 - REAR-TO-REAR
                                                                                                                                                                   1 - NORTH                1 - DIVIDED FLUSH MEDIAN
                 ON SHOULDER                 10 - DRIVEWAY/ALLEY ACCESS                         BETWEEN          5 - BACKING                                       2 - SOUTH                    (<4 FEETI
                 IN MEDIAN                   11 - RAILWAY GRADE CROSSING                        TWO MOTOR
                                                                                                                 6 - ANGLE                                         3 - EAST                2 - DIVIDED FLUSH MEDIAN
                 ON ROADSIDE                 12 - SHARED USE PATHS OR                           VEHICLES IN
                                                                                                                 7 - SIDESWIPE, SAME OIREaiON                     4 - WEST                      f a4 FEET1
                                                                                                TRANSPORT
                 ON GORE                         TRAILS                                                                                                                                    3 - DIVIDED, DEPRESSED MEDIAN
                                                                                                                 8 - SIDESWIPE, OPPOSITE DIREaiON
                 OUTSIDE TRAFFIC WAY         13-BIKE LANE                                     2 - REAR-END
                                                                                                                                                                                           4 - DIVIDED, RAISED MEDIAN
                 ON RAMP                     14-TOU BOOTH                                                        9 - OTHER / UNKNOWN                                                            (ANY TYPE1
              8 - OFF RAMP                   99-OTHER/UNKNOWN                                                                                                                              9 - OTHER / UNKNOWN
Q WORK ZONE RELATED WORK ZONE TYPE LOCATION OF CRASH IN WORK ZONE CONTOUR CONDITIONS SURFACE
NARRATIVE
     On 3/14/2020- Unit 1 traveling South on Amelia Olive Branch crossed center and
     struck unit 2 head on. The roadway was curved and wet. The driver of both units
                                                                                                                                                                                                                      (D
     were transported to University of Cincinnati Medical Center, Both passengers of unit                                                         «na 0(tv« Branch Road
     2 were juvenile and transported to Cincinnati Children's Hospital. Both vehicles were
     not operable and towed. Airbags deployed in unit 1 but not unit 2. A vehicle
     inventory search was completed. A cut straw and powder was found inside a Rx
     bottle in unit 1.
     I made contact with both drivers at University Medical Center. Unit 2 estimated his
     speed around 40 MPH. Unit 1 didn't know how fast he was going and does not
     know what happened.
     Unit 1 is believed to be impaired and was read the BMV 2255 witnessed by staff. A
     test was offered and refused.
Dep. M. Ross
#2064
To Sc^J^
CRASH REPORTED DATE / TIME DISPATCH DATE / TIME ARRIVAL DATE/TIME SCENE CLEARED DATE / TIME REPORT TAKEN BY
              03/14/2020 16:00                                  03/14/2020 16:00                              03/14/2020 16:00                                   03/14/2020 20:00                     IS POLICE AGENCY
      TOTAL TIME                 OTHER                                  OFFICER'S NAME*                                              Checked by OFFICER'S NAME*
                                                                                                                                                                                                      □ MOTORIST
                                                          TOTAL
ROADWAY CLOSED INVESTIGATION TIME                      MINUTES          Dep. M. Ross                                                 Scott, D                                                         □supplement
                                                                                                                                                                                                           (CORRECTION Oit ADDITION
                                                                                    OFFICER'S BADGE NUMBER*                                    CHECKED BY OFFICER'S BADGE NUMBER*                          TO AN EXISTING REPORT SENT TO
                                                          240                                    2064                                                          R2367                                       ODPS)
                            Case: 1:25-cv-00481-DRC-KLL Doc #: 4-2 Filed: 08/08/25 Page: 17 of 26 PAGEID #: 255
                                                                                                                                                                                                                 LOCAL REPORT NUMBER
                                                                                                                                                                                                                      002000010951
                                      'AME: LAST. FIRST, MIDDLE (□ SAME AS DFIVEA)                                          OWNER PHONE :iNCLUDf AREA CODE(G SAME AS ORIVER)                                            DAMAGE
OWNER ADDRESS: STREET, CITY. STATE, ZJPiG s»vi; as d«ve"! 1 - NONE 3 • FUNCTIONAL DAMAGE
3898 VINEYEARD GREEN DR., CINCINNATI, OH, 45255 2 - MINOR DAMAGE 4 - OlSABUNG DAMAGE
                                                                                                                                                                                                                      DAMAGED AREAfST
                                                                                                                                                                                                                 INDICATE ALL THAT APPLY
LP STATE                LICENSE PUTE #                                         VEHICLE IDENTIFICATION «                                   VEHICLE YEAR            VEHICLE MAKE
r~lcOMMERClAt 1 Igovernment
     ^INTERLOCK
                                                         s
                                                             N EMERGENCY
                                                             RESPONSE
                                                             « OCCUPANTS
                                                                                     VEHICLE WEIGHT GVWR/GCWR
                                                                                                 1 - STOKIBS,
                                                                                                                              AUTO WORKS
                                                                                                                              j—IMATERIAL
                                                                                                                                             HAZARDOUS MATERIAL
                                                                                                                                                        CLASS#         PLACARD ID#
                                                                                                                                                                                                                                     tay I                    V"
1 [device                         1 1 HIT/SKIP UNIT                                  I        I 2 • 10.001 • 26K IBS,         ^RELEASED
      EQUIPPED
                                                                       1             I        1 3 - > 26K LBS.                LJplacard             I            I I                  I
                         1 - PASSENGER CAR          6-VAN(9-155EATS)                         12 - GOLF CART            18-LIMO (LIVERY VEHICLE)         23 - PEDESTRIAN/SKATER
                        2 - PASSENGER VAN           7 - MOTORCYCLE 2-WHEELEO                 13 - SNOWMOBILE           19 - BUS (16» PASSENGERS)         24 - WHEELCHAIR (ANY TYPE)
                             (MINIVAN)              6 - MOTORCYCLE 3-WHEELEO                 14-SINGLE UNIT
                                                                                                                       20-OTHER VEHICLE                 25 - OTHER NON-MOTORIST
                        3 - SPORT UTILIIV           9-AUTOCYCLZ                                 TRUCK
                                                                                                                       21 - HEAVY EQUIPMENT             26- BiaCLE
                             VEHICLE
                        4 - PICKUP
                                                    10 - MOPED OR MOTORIZED
                                                         BICYCLE
                                                                                             15 - SEMI TRAaOR
                                                                                             16-FARM EQUIPMENT
                                                                                                                       22 - ANIMAL WITH RIDER OR        27 • TRAIN
                                                                                                                          ANIMAL-DRAWN VEHICLE gg . UNKNOWN OR HIT/SKIP
                                                                                                                                                                                                                 L m j'
                         55-CARGO
                            - CARGO VAN             11 - ALL TERRAIN VEHICLE                 17 - MOTOHHOME
                                         (ATVA7TV)
                        «OF TRAILING UNITS
                         1 - NON-CONTACT                     1 - STRAIGHT AHEAD                 9 - LEAVING TRAFFIC            15-WALKING, RUNNING,          21 - STANDING OUTSIDE                           INITIAL POINT OF CONTACT
                                                                                                                                  JOGGING, PLAYING
                      2 - NON-COLLISION''           ^1       2 - BACKING
                                                             3 - CHANGING LANES
                                                                                                  LANE
                                                                                                                                                             99-OTHER/UNKNOWN
                                                                                                                                                                                                       0 - NO DAMAGE             14 • UNDERCARRIAGE
I ^                 I 3-STRIKING         II                i 4 - OVERTAKING/PASSING             11 - SLOWING OR STOPPED        IT-PUSHING VEHICLE                                           12      I V12-REFER TO UNIT IS - VEHICLE NOT AT SCENE
    Az-rinki
    ACTION              4.4TRUCI:
                                               PRE-CRASH
                                               PRE-CRAS      S-MAKING RIGHT TURN                  IN TRAFFIC                   18-APPROACHING OR                                            —-—I                 DIAGRAM
                                  ^            ACTION;
                                               ACTIONS       6 - MAKING LEFT TURN               12-DRIVESLESS                     LEAVING VEHICLE                                                                                99 - UNKNOWN
                         5- BOTH STRIKING                    7 ■ MAKING U-TURN                                                                                                                          13 - TOP
                                                                                                13 - NEGOTIATING A CURVE       19-STANDING
                            8i STRUCK
                                                             8 - ENTERING TRAFFIC               14 - ENTERING OR CROSSING      20 - OTHER NON-MOTORlST
                        9-OTHER/UNKNOWN
                                     DWN                       LANE                                SPECIFIED LOCATION
                            1 - NONE                         8 - FOaOWlNG TOO CLOSE            13 • IMPROPER START FROM       18-OPERATING DEFECTIVE          23 - OPENING DOOR INT
                                                                                                                                                                                          TRAFFICWAV FLOW
                            2 - FAILURE TO YIELD                   /ACDA                           A PARKED POSITION             EQUIPMENT                           ROADWAY
                                                                                                                                                                                                   1 - ONE-WAY
                            3 - RAN RED LIGHT                9-IMPROPER LANE                    14 - STOPPED OR PARKED        19-LOAD SHIFTING                99-OTHER IMPROPER
                                                                                                                                                                                                   2 - TWO-WAY
          y                 4-RAN STOP SIGN                    CHANGE                              ILLEGALLY                      /FALUNG/SPILLING                   ACTION
I                   1       5-UNSAFE SPEED                   10-IMPROPER PASSING                15-SWERVINGTO AVOID           20 - IMPROPER CROSSING
CONTRIBUTINO 6-IMPROPER TURN                                 11 - DROVE OFF ROAD                16-WRONG WAY                  21 - LYING IN ROADWAY
CIRCOMSTAMCESj.^j^Qf CENTER                                  12 • IMPROPER BACKING              17-VI5fON OBSTRUCTION         22-NOT DISCERNIBLE                                                                              RAIL GRADE CROSSING
                                                                                                                                                                                                                              1 -NOTINVLOVED
SEOUENCE OF EVENTS                                                                                                                                                                                                            2 - INVOLVED-ACTIVE CROSSING
                                                                                                         EVENTS                                                                                                              I 3 - INVOLVED-PASaVE CROSSING
                            1 -OVERTURN/ROLLIDVER           7 - SEPARATION OF UNITS             12 • DOWNHILL RUNAWAY         19 - ANIMAL -OTHER            23-STRUCK BY FAILING,
                            2 - FIRE/EXPLOSION              8-RAN OFF ROAD RIGHT                13 - OTHER NON-COLLISION      20 - MOTOR VEHICLE IN             SHIFTING CARGO OR
                            3 - IMMERSION                   9- RAN OFF ROAD LEFT                14 - PEDESTRIAN                   TRANSPORT                     ANYTHING SET IN                         UNIT / NON-MOTORIST DIRECTION
                            4-jACKKNIFE                                     .N
                                                            10 - CROSS MEDIAN                   15 • PEOALCYCLE               21-PARKEOMOTOR                     MOTION BY A MOTOR
                                                                                                                                                                                                                             1-NORTH           5-NORTHEAST
                                                                                                                                                                 VEHICLE
                            5-CARGO/EQUIPMENT               11 - CROSS CENTERLINE-
                                                                            RUNE -              16 - RAILWAY VEHICLE               VEHICLE
                                                                                                                                                            24 - OWER MOVABLE                                                2-SOUTH           6-NORTHVrt5T
                               LOSS OR SHin                                    ECTION
                                                                   OPPOSITE DIRECTION           17-ANIMAL- FARM               22 - WORK ZONE
                                                                                                                                                                 OBJECT
                            6-EQUIPMENT FAILURE                    OF TRAVEL                    18 - ANIMAL • DEER                MAINTENANCE
                                                                                                                                  EQUIPMENT
                                                                                                                                                                                      002000010951
                        ;ME: L.VST flRST, MIDDLE lO SAV€AS3IUVf»J                                         OWNER PHONE;iNai;c( MiA <03EiD sami asooivc")
                                                                                                                                                                                        DAMAGE SCALE
                                                                                                                                                                                       DAMAGED AREA(S)
                                                                                                                                                                                    INDICATE ALL THAT APPLY
                                                                 VEHICLE IDENTIFICATION #                             VEHICLE YEAR          VEHICLE MAKE
                                                                                                                         2010                    CHEVROLET
                                                                       INSURANCE POLICY#                                 COLOR             VEHICLE MODEL
                                                                                                                            DBL                   COBALT
                                                                                                            TOWED BY:COMPANY NAME
                     I [government I I IN EMERGENCY
                                                                                                            BOB MYERS
                                       RESPONSE
                                                                   VEHICLE WEIGHT GVWR/GCWR                              HAZARDOUS MATERIAL
                                                                                                           [—IMATERIAL            clAjS• PLACARD ID #
                  I |hit/skipunit                                              1 • 210KLBS.
                                                                               2• 10.001 - 26K LBS.        ^RELEASED                                                    vm.i v "
                                                                               3 - > 26K LBS.               I Iplacard
            1 - PASSENGER CAR         6-VAN (9-15 SEATS)                                            18-LIMO(LIVERY VEHICLE)         23 - PEDESTRIAN/SKATER
    ..     2 - PASSENGER VAN          7 - MOTORCYCLE 2-WHEELED             13-SNOWMOBILE            19 - BUS(16-' PASSENGERS)       24 - WHEELCHAIR (ANY TYPE)                    10
     I          (MINIVAN)             8 - MOTORCYCLE 3-WH£ELfD             U-SINGLE UNIT
                                                                                                                                   2S - OTHER NON-MOTORIST
                                                                                                    20-OTHER VEHICLE
                                      9-ALITOCYCLE                            TRUCK
UNITTYPE                                                                                            21 • HEAVY EQUIPMENT
                VEHICLE                                                    15 - SEMI-TRACTOR
                                      10 - MOPED OR MOTORIZED
                                                                                                      - ANIMAL WITH RIPER OR
                                                                                                    22-ANIMAL                      27 - TRAIN
                                           BICYCLE                         16-FARM EQUIPMENT
                                                                                                        ANIMAL-DRAWN VEHICLE 9,.UNKNOWN OR HIT/SKIP
           5-CARGO VAN                11 - ALL TERRAIN VEHICLE             17-MOTORHOME
                             (ATVAITV)
           « OF TRAILING UNITS
                                                                                                                                                                        Q- NO DAMAGE[01              Q- UNDERCARRIAGE[ U ]
                                               4-MIDBLOCK-                    7 - SHOULDER/ROADSIDE         10-DRIVEWAY ACCESS           99 - OTHER/UNKNOWN
                                 ;WAIK               MARKED CROSSWALK                                       11 -SHARED USE PATHS                                        Q.TOP[131                    D- ALL AREAS(IS]
                                               5 - TRAVEL LANE-                                                 OR TRAILS
                                                                              9-MEDIAN/CROSSING
                                 3SSWAIK            OTHER LOCATION
                                                                                   ISLAND
                                                                                                            12-FIRST RESPONDER                                                    PI- UNIT NOT AT SCENE[ 16]
                                 OTHER         6 • BICYCLE LANE                                                 AT INCIDENT SCENE
               1•NONE                         8 - FOaOWING TOO CLOSE         13 - IMPROPER START FROM       IS - OPERATING DEFECTIVE     23 - OPENING DOOR INTO
                                                                                                                                                                   TRAFFICWAY FLOW                  TRAFFIC CONTROL
               2 • FAILURE TO YIELD                  /ACOA                         A PARKED POSITION           EQUIPMENT                        ROADWAY
                                                                                                                                                                                                    1-ROUNDABOUT    4-STOP SIGN
               3-RAN RED LIGHT                 9-IMPROPER LANE                14 - STOPPED OR PARKED        19 - LOAD SHIFTING           99 • OTHER IMPROPER
    •]         4-RAN STOP SIGN                   CHANGE                             ILLEGALLY                  /FALLING/SPILLING                ACTION
               S • UNSAFE SPEED                to-IMPROPER PASSING            15-SWERVING TO AVOID         20-IMPROPER CROSSING
CONHUBUTINS 5.improper TURN                    II - DROVE OFF ROAD           15-WRONG WAY                   21 - LYING IN ROADWAY
                                               12-IMPROPER BACKING            17 - VISION OBSTRUCTION      22 - NOT DISCERNIBLE                                   #OF THROUGH LANES             RAIL GRADE CROSSING
                                                                                                                                                                       ON ROAD                  1 -NOTINVLOVED
SEOUENCE OF EVENTS                                                                                                                                                                              2•INVOLVED-ACTIVE CROSSING
                                                                                                                                                                                                002000010951
        A1               I: LAST
                            LAST,FIRST, MIDDLE                                                                                                                                        DATE OF BIRTH                              AGE         GENDER
    ;§ INJURIES INJURED        EMS AGENCY(NAME)                                        INJURED TAKEN TO:MEOKAl FAOUTir(name,city)          SAFETY EQUIPMENT                                     SEATING      AIR BAG USAGE       EJECHON      TRAPPED
                                                                                                                                           USED                          DOT-Compuant          POSITION
28 M
ADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CODE
INJURIES INJURED EMS AGENCY (NAME) INJURED TAKEN TO: Medkal FaciutY (NAME, city) SAFETY EQUIPMENT SEATING AIR BAG USAGE EJECTION TRAPPED
ADDRESS: STREET, CITY. STATE, ZIP CONTACT PHONE - INCLUDE AREA CODE
       INJURIES INJURED        EMS AGENCY (NAME)                                       INJURED TAKEN TO: MEOKAl FACIUTY (NAME. CITY)       SAFETY EQUIPMENT                                     SEATING      AIR BAG USAGE EJECTION           TRAPPED
                 TAKEN                                                                                                                     USED                |—iDOT-Compuant                 position
                                                                                                                                                               □ M C HELMET
      OL STATE OPERATOR UCENSE NUMBER                                                  OFFENSE CHARGED                            LOCAL     OFFENSE DESCRIPTION                                              CITATION NUMBER
                                                                                                                                   CODE
                                                                                                                                       □
      OL CLASS      ENDORSEMENT       RESTRICTION SELECT UP TO 3             DRIVER                  ALCOHOL/DRUG SUSPECTED                  CONDITION                   ALCOH OL TEST                              DRUG TEST(S)
                                                                             DISTRACTED □ ALCOHOL                    □ MARIJUANA                              STATUS TYPE                   VALUE          STATUS        TYPE     RESULTS SUKI UP 10 4
                                                                             BY                  I—I
                                                                                                 I   I OTHER DRUG
                                                                                                                                                                            H            M
ADDRESS:
INJURIES INJURED       EMS AGENCY (NAME!             INJURED TMEN TO. Medkal FACILITY(MAMt Cl'V)           SAFETY EQUIPMENT                      SEATING    AIR BAG USAGE   EJECTION   TRAPPED
           TAKEN       UNION TWP.                                                                                              IDOT-Compuakt position
                                                                                                                                MC HELMET          a
   4       BY      2                                 CHILDRENS HOSPITAL                                           5                                                           1           1
 UNIT #    NAME; LAST, FIRST, MIDDLE                                                                                                       DATE OF BIRTH                    AGE        GENDER
                                                                                                                                          12/29/2010
ADDRESS; STREET, CITY, STATE, ZIP                                                                                             CONTACT PHONE • INCLUDE area CODE
                                                     INJURED TAKEN TO MlOKAl FACIUTr(name,crvj             SAFETY EQUIPMENT                     SEATING     AIR BAG USAGE   EJECTION   TRAPPED
INJURIES INJURED
           TAKEN
                       EMS Agency inauf>
                       UNION TWP,                                                                                             □DOT-Cohpuant     POSITION
   4       BY      2                                 CHILDRENS HOSPITAL                                           5
                                                                                                                                MC HELMET          g                1         1           1
 UNIT 0    NAME: LAST, FIRST, MIDDLE                                                                                                       DATE OF BIRTH                    AGE        GENDER
ADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE • INCLUDE AREA CODE
INJURIES INJURED       EMS AGENCY jnamej             INJURED TAKEN TO: MlOKAl FaCIUTY (name, CI-v)         SAFETY EQUIPMENT                      SEATING    AIR BAG USAGE   EJECTION   TRAPPED
                                                                                                                                iDOT-Compuamt   POSITION
           TAKEN
ADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE • INCIUDE AREA CODE
INJURIES INJURED       EMS AGENCY iNAMEi             INJURED TAKEN TO: MEOKAl FACIUTY (NAMt crv)           SAFETY EQUIPMENT                      SEATING    AIR BAG USAGE   EJECTION   TRAPPED
           TAKEN
                                                                                                                                iDOT-Compuakt   position
           BY
                                                                                             15 - NON-MOTORIST                                  3 - FREED BY
                                                                                             99-OTHER/UNKNOWN                                       NON-MECHANICAL MEANS
ADDRESS: STREET, CITY, STATE. ZIP                                                                                             CONTACT PHONE - iFjrLlIOE AREA CODE
                                Case: 1:25-cv-00481-DRC-KLL Doc #: 4-2 Filed: 08/08/25 Page: 21 of 26 PAGEID #: 259
             rnme:       3/15/2020 12:11 am
EXHIBIT      lumber:       2000953                    Location of Offense:      6271 MANILA RD, Goshen, OH 45122
  A2         ise Code: 4511.IQAIA-Driving While Under the Influence of Alcohol and/or Drugs
              Arrestee: Mitchert, Brandon Kenneth                                  Age: 22                       Gender Male
                Arrest Date: 3/15/2020 3:12:58AM Arrest Location: 6271 MANILA RD, GOSHEN,OH 45122
                                                                                                                                  89 of   100
EXHIBIT
            tn ime:
              umber:
              Ul
                                Case: 1:25-cv-00481-DRC-KLL Doc #: 4-2 Filed: 08/08/25 Page: 22 of 26 PAGEID #: 260
                        3/14/2020 3:45 am
                           2000942                    Location of Offense:        4795 SHARPS CUTOFF RD, Batavia, OH 45103
  A2          se
              S( Code: 2925.1 ICI-Possession of Drugs _ schedule I or II substance
    Offense Number:        2000943                    Location of Offense:         Old SR 74/Stonelick Woods Drive, Batavia, OH 45103
         Offense Code: 2903.13-Assault
               Arrestee: Tolliver, Amanda M.                                         Age: 32                Gender Female
                 Arrest Date: 3/14/2020 4:06:14AM Arrest Location: 128 St Louis Dr, Owensville, OH 45160
         Offense Code: 2921.331 B-Failure to Comply with Order or Signal of P.O. _ elude or flee
               Arrestee: Tolliver, Amanda M.                                         Age: 32                Gender Female
                 Arrest Date; 3/14/2020 4:06:14AM Arrest Location: 128 St Louis Dr, Owensville, OH 45160
         Offense Code: 2921.33A-Resisting Arrest _ resist or interfere
               Arrestee: Tolliver. Amanda M.                                         Age: 32                Gender Female
                 Arrest Date: 3/14/2020 4:06:14AM Arrest Location: 128 St Louis Dr, Owensville, OH 45160
         Offense Code: 2925.11-Possession of Drugs
               Arrestee: Tolliver, Amanda M.                                         Age: 32                Gender: Female
                 Arrest Date: 3/14/2020 4:06:14AM Arrest Location: 128 St Louis Dr, Owensville, OH 45160
         Offense Code: 4511.19A1A-Driving While Under the Influence of Alcohol and/or Drugs
               Arrestee: Tolliver, Amanda M.                                         Age: 32                Gender: Female
                 Arrest Date: 3/14/2020 4:06:14AM Arrest Location: 128 St Louis Dr, Owensville, OH 45160
                                                                                                                                        88 of   100
                                 Case: 1:25-cv-00481-DRC-KLL Doc #: 4-2 Filed: 08/08/25 Page: 23 of 26 PAGEID #: 261
pyIIIp|*r
C.A nIDI I jrrime: . 3/13/2020
                       2000931 5:13pm         Location of Offense: 1874 BIG INDIAN RD, Moscow, OH 45153
   A2       Jise Code: 2913.02A1-Theft _ without consent
 Offense Date/Time: 3/13/2020 7:30 pm
    Offense Number: 2000936                          Location of Offense:        2780 LINDALE MT HOLLY RD, Amelia, OH 45102
         Offense Code: 2903,11A2-Felonious Assault _ weapon or ordnance
     Offense Number:        2000938                  Location of Offense:        2780 LINDALE MT HOLLY RD,Amelia, OH 45102    Lot 176
         Offense Code: 2919.27-Violate Protection Order or Consent Agreement
                                                                                                                                                           87 of   100
                               Case: 1:25-cv-00481-DRC-KLL Doc #: 4-2 Filed: 08/08/25 Page: 24 of 26 PAGEID #: 262
             Time:     3/12/2020 10:43 am
EXHIBIT     lumber:       2000927                    Location of Offense:        49 CHARMALEE DR, Amelia, OH 45102
  A2         ise Code: 2911.12-Burglary
              Arrestee: Dale, Robert James                                          Age: 27                      Gender Male
               Arrest Date: 3/24/2020 11:37:54AM Arrest Location: 961 Old US Hwy 52, New Richmond. OH 45157
   Offense Number:        2000928                    Location of Offense:        49 CHARMALEE DR, Amelia, OH 45102
        Offense Code: 2903.13A-Assault_ knowingly harm victim
             Arrestee: Dale, Robert James                                           Age: 27                      Gender Male
               Arrest Date: 3/12/2020 2:15:02PM Arrest Location: 961 Old US Hwy 52. New Richmond, OH 45157
                                                                                                                                86 of   100
          Case: 1:25-cv-00481-DRC-KLL Doc #: 4-2 Filed: 08/08/25 Page: 25 of 26 PAGEID #: 263
                                                                        OHIO DEPARTMENT OF PUBLIC SAFETY
EXHIBIT                                                                    BUREAU OF MOTOR VEHICLES
   A3
                          REPORT OF LAW ENFORCEMENT OFFICER ADMINISTRATIVE LICENSE SUSPENSION I
                            NOTICE OF POSSIBLE CDL DISQUALIFICATION / IMMOBILIZATION I FORFEITURE
                                                                                            DRIVER UCENSE#^                                                CLASS                 STATE^i
  VEHiaESTOR^fllj^gEET^A^pjg^^                                                                                                                      CITY
 B. Officer to ComiiletB for All OVI/ Physical Control Arrests:
    Circle anest type: OVI Physical Control                                             and / or for the presence of any controlled substance or melabotite. My teyonable grounds for
                                                                                        OVI IPhypi^l Contretgrrest leto test rjtere:               ^ ^
     Tfte driver
    ^d^efused lo submit to lest(s).                                                                                                                        -eyi
                                                                                        □ Sub{ecl tested fiix coniroBed substance or metalx^e. Circfe lest type for
                                                                                                                                                                    rjh}^
                                                                                                                                                                    whloi controlled
                                                                                                                                                                lorwhlai  controile substance
     □ Submitted to lest (s).0,              3^ alcohol test result                       or metabolite results were reported: Urine, Whole Blood, Blood Serum, or Blood Plasma,
     □ Cirde test type for which results were reported:                                 □ Specify ooniroUed substance and I or metabolite results:.
          Whola Blood, Breath, Urine, Blood Serum, or Blood Plasma                      □ Subject tested positive for prohibiled level of marihuana metatw&te.             .(speciiy amount)
     Q Was placed under an Administrative Ucense Suspension (R.C. 4511.191)                 and was under the inlluenoe of atcohcl and / or a dreg of abuse.
     □ License was seized                                                               □ Alcohol, controlled substance or metabofiie test result received cn_                   ..Subject served
     □ OffetHler was provided a copy of this form at the time of anest                      vrilh notice of Administrative Ucense Suspension on
                                                                                        ^Reasonable means oHicer used to ensure offender submitted to a chemical test were:
 C. Officer to Complete Applicable Vehicle SanctJona:                                   □ Vehicle seized under R.C. 4510.41 only (DUS or wrongful entrustment of a motor vehicle) If so, Do
    □ License plate(s] seized                                                               not mall this form to the BMV         '
    □ Vehicle seized under R.C. 4511.195 (OVI)                                          □ Vehicle sut^ to immobilization
                                                                                        □   Vehlda subject to forfeiture
 0. OfRcer to Complate if Offender Is the holder of a commerdal driver                  □   Prohibited Alcohol Content wtlh OVI charge
     license or was Operating a Commeiclal Vehicle:                                     □   Cwnmercial vehicle per definition (R.C. 4506.01 (E))
     □ Read and showed advice to offender (R.C. 4506.17)                                □   24-hour out-of-servioe order
     □ Refused to submil to test(s)                                                     □ CDLtobedisquatilied
     □ Submitted to tesl(s) 0.          % ateohol test result                           □ COL seized
          (Circle One) Whole Blood. Breath, Urine, Blood Serum, or Blood Plasma         n Hazardous material
     □ Prohibited Alcohol Content vrithout OVI charge                                   □J Operated a conur^ai
                                                                                                      comniefdai vehide
                                                                                                                 vehicle under the intiuoice
                                                                                                                                   infhioice 01
                                                                                                                                             of ia controlled substance
 E. The advice on the back of this form was read to me and I have received a
    copy cf this form.   UJ
                          £-
                                                                                        X
                                                                                          rivwssignaAre^                                     •
                                                                                                                                                                 ^i^^USEDTOSlGN
 P. Compteta Below Only for an OVI/Physical Control ARf^T:
     We, the undersigned, certi^ that the advice prescribed by the General Assembly (under R.C. 4511.191 and R.C. 4511.192), was shewn to the person under arrest and read to him or her in
            ssence of the atrestir^ officer and onapHw person^
                                                                                                                                                                         1                  lg> I
         iGO^lCEf^ SIGNATURE
 ARRESTING                                                                            ENFORCEMENT AGEN                                                                        N.C.I.C.#
 COMPLETE BaOW ONLY ON OVI ARREST                                                    OR ARREST INVOLVING COiffiSERCIAL VEHICLE. AFRDAVIT OF ARRESTING OFFICER;
 STATE OF OHIO. COUNTY OF _
 I certify I arrested the person, having had reisonaSe
                                             reasonable grounds to believe (he person
                                                                               perse was operating a vehide iq»n a highway, or upon public or prfvata property used by the public for vehicular
 travel or parking in the State of Ohio, under the influence of alcohol and / crdrer|sctabuse. In phy^cal control of a vehide while under the tniiuenoe of alcohol and / ordrufls of abuse, or with a
 prohibited concentration of alcohol ki the whole blood, blood serum, blood pla^, bream, or urine. I advised the person in the prescribed matmar of the consequences of a refusal or a tesL
 The person either refused the lesL or was under arrest for OVi and took the test and had a prohibited concentration of alcohol in the whole blood, blood serum, blood plasma, breath, or urine
 (all as described aT5v^(n the case of a oommerolal vehide (if apprwabfe) I had reasonable grounds to believe the person was driving a commerdal nutor vehide in the State of Ohio in
 violation cf section 4SQ6.15 of the     Revised Code. The hiformatlon contained on this form is true to the best of my knowledge and belief.
                                                                                                                X
    ARREtfffilG OFFICER SIGNATURE                                                                               PEACE OFFICER SIGNATURE
06/30/2025 1/27/1980
                                                      DRIVER INFORMATION
                                                                           SOCIAL SECURITY NUMBER   OL/ID NUMBER                 DATE OF ISSUANCE
ENDORSEMENTS: NONE
WITHDRAWALS
                                                                 CONVICTIONS
    C3     OUT-OF-STATE CONVICTION
C3 OUT-OF-STATE CONVICTION