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Tute caregivers and all persons 18 years of age and older who reside in a type B home. This statement must be kept on file at the home or County Department of Job and Family Services (CDJFS). Name (please print or type) I hereby attest that I have never been convicted of or pleaded guilty to crimes set forth in divisions (A)(8) or (A)(9) of section 109.572 or division (A)(1) of 5104.09 of the Revised Code and that no child has been removed from my home as described in section 2151.353 of the Re.

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