I hereby declare under penalty of perjury under the laws of the State of Ohio that the information provided in this claim form is true, correct, and complete to the best of my knowledge and belief.

I understand that making a false statement or providing fraudulent information in connection with this claim may constitute a criminal offense and may result in denial of the claim, civil liability, and/or criminal prosecution.

I further certify that I am the rightful owner of the item(s) described herein, or am authorized to file this claim on behalf of the owner, and that I have not received compensation from any other source for the damage or loss described in this claim.