Criminal Background Statement

I hereby state and affirm that I have not been convicted of, plead guilty to, or been found eligible for intervention in lieu of conviction for:

1) Any of the disqualifying offenses as listed in the Ohio Revised Code 5123:2-2-02 Section E(1)(a)(i) to E(1)(d)(xli). See list on back. (A candidate shall disclose a conviction for any offense that has been sealed per rule 5123:2-2-02(D)(3). 2) 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity) when the underlying offense is any of the offenses or violations described above; or 3) A conviction related to fraud, theft embezzlement, breach of fiduciary responsibility, or other financial misconduct involving a federal or state-funded program, excluding the disqualifying offenses set forth in section 2913.46 of the Revised Code (illegal use of supplemental nutrition assistance program or women, infants, and children program benefits); or 4) A violation of an existing or former municipal ordinance or law of Ohio, any other states, or the United States, which is substantially equivalent to any of the offenses or violations described above.

I understand that United Disability Services will obtain a written report of my criminal background and that my employment is contingent upon the results of the report. I understand that UDS will terminate my employment if it is learned that I failed to inform them that I have been convicted of, plead guilty to, or been found eligible for intervention in lieu of conviction for any of the prohibited offenses described above.

Furthermore, I agree to notify Human Resources within 14 calendar days if ever formally charged with, convicted of, plead guilty to, or been found eligible for intervention in lieu of conviction for any of the prohibited offenses during the course of employment. I understand that failure to report formal charges, a conviction, a guilty plea, or an intervention in lieu of conviction for a disqualifying event to Human Resources may result in dismissal from employment.

Date Signature

Name Printed

DocuSign Envelope ID: 6B0AE150-68A0-4626-B0D5-7CCA065695AA 5/12/2023

Michael Jones

5123:2-2-02 Section E(1)(a)(i) to E(1)(d)(xli)

Tier 1 Disqualifying Offenses (Permanent Exclusion):

(a)(i) 2903.01 (aggravated murder);

(a)(ii) 2903.02 (murder);

(a)(iii) 2903.03 (voluntary manslaughter);

(a)(iv) 2903.11 (felonious assault);

(a)(v) 2903.15 (permitting child abuse);

(a)(vi) 2903.16 (failing to provide for a functionally impaired person);

(a)(vii) 2903.34 (Patient abuse and neglect);

(a)(viii) 2903.341 (patient endangerment);

(a)(ix) 2905.01 (kidnapping);

(a)(x) 2905.02 (abduction);

(a)(xi) 2905.32 (human trafficking);

(a)(xii) 2905.33 (unlawful conduct with respect to documents);

(a)(xiii) 2907.02 (rape);

(a)(xiv) 2907.03 (sexual battery);

(a)(xv) 2907.04 (unlawful sexual conduct with a minor, formerly corruption of a minor);

(a)(xvi) 2907.05 (gross sexual imposition);

(a)(xvii) 2907.06 (sexual imposition);

(a)(xviii) 2907.07 (importuning);

(a)(xix) 2907.08 (voyeurism);

(a)(xx) 2907.12 (felonious sexual penetration);

(a)(xxi) 2907.31 (disseminating matter harmful to juveniles);

(a)(xxii) 2907.32 (pandering obscenity);

(a)(xxiii) 2907.321 (pandering obscenity involving a minor);

(a)(xxiv) 2907.322 (pandering sexual oriented matter involving a minor);

(a)(xxv) 2907.323 (illegal use of minor in nudity-oriented material or performance);

(a)(xxvi) 2909.22 (soliciting/providing support for act of terrorism);

(a)(xxvii) 2909.23 (making terrorist threat);

(a)(xxviii) 2909.24 (terrorism);

(a)(xxix) 2913.40 (medical fraud);

Tier 2 Disqualifying Offenses (Ten-Year Exclusion):

(b)(i) 2903.04 (involuntary manslaughter);

(b)(ii) 2903.041 (reckless homicide);

(b)(iii) 2905.04 (child stealing) as it existed prior to 7/1/1996;

(b)(iv) 2905.05 (criminal child enticement);

(b)(v) 2905.11 (extortion);

(b)(vi) 2907.21 (compelling prostitution);

(b)(vii) 2907.22 (promoting prostitution);

(b)(viii) 2907.23 (enticement or solicitation to patronize a prostitute, procurement of a prostitute for another);

(b)(ix) 2909.02 (aggravated arson);

(b)(x) 2909.03 (arson);

(b)(xi) 2911.01 (aggravated robbery);

(b)(xii) 2911.11 (aggravated burglary);

(b)(xiii) 2913.46 (illegal use of supplemental nutrition assistance program or women, infants, and children program benefits);

(b)(xiv) 2913.48 (workers’ compensation fraud);

DocuSign Envelope ID: 6B0AE150-68A0-4626-B0D5-7CCA065695AA

(b)(xv) 2913.49 (identity fraud);

(b)(xvi) 2917.02 (aggravated riot);

(b)(xvii) 2923.12 (carrying concealed weapon);

(b)(xviii) 2923.122 (illegal conveyance or possession of deadly weapon or dangerous ordinance in a school safety zone, illegal possession of an object indistinguishable from a firearm in a school safety zone);

(b)(xix) 2923.123 (illegal conveyance, possession, or control of deadly weapon or dangerous ordnance into courthouse);

(b)(xx) 2923.13 (having weapons while under disability);

(b)(xxi) 2923.161 (improperly discharging a firearm at or into a habitation or school);

(b)(xxii) 2923.162 (discharge of firearm on or near prohibited premises);

(b)(xxiii) 2923.21 (improperly furnishing firearms to a minor);

(b)(xxiv) 2923.32 (engaging in pattern of corrupt activity);

(b)(xxv) 2923.42 (participating in criminal gang);

(b)(xxvi) 2925.02 (corrupting another with drugs);

(b)(xxvii) 2925.03 (trafficking in drugs);

(b)(xxviii) 2925.04 (illegal manufacture of drugs or cultivation of marijuana);

(b)(xxix) 2925.041 (illegal assembly or possession of chemicals for the manufacture of drugs);

(b)(xxx) 3716.11 (placing harmful objects in food or confection); Tier 3 Disqualifying Offenses (Seven-Year Exclusion):

(c)(i) 959.13 (cruelty to animals);

(c)(ii) 959.131 (prohibitions concerning companion animals);

(c)(iii) 2903.12 (aggravated assault);

(c)(iv) 2903.21 (aggravated menacing);

(c)(v) 2903.211 (menacing by stalking);

(c)(vi) 2905.12 (coercion);

(c)(vii) 2909.04 (disrupting public services);

(c)(viii) 2911.02 (robbery);

(c)(ix) 2911.12 (burglary);

(c)(x) 2913.47 (insurance fraud);

(c)(xi) 2917.01 (inciting to violence);

(c)(xii) 2917.03 (riot);

(c)(xiii) 2917.31 (inducing panic);

(c)(xiv) 2919.22 (endangering children);

(c)(xv) 2919.25 (domestic violence);

(c)(xvi) 2921.03 (intimidation);

(c)(xvii) 2921.11 (perjury);

(c)(xviii) 2921.13 (falsification, falsification in theft offense; falsification to purchase firearm, or falsification to obtain a concealed handgun license);

(c)(xix) 2921.34 (escape);

(c)(xx) 2921.35 (aiding escape or resistance to lawful authority);

(c)(xxi) 2921.36 (illegal conveyance of weapons, drugs, or other prohibited items onto grounds of detention facility or institution);

(c)(xxii) 2925.05 (funding of drug or marijuana trafficking);

(c)(xxiii) 2925.06 (illegal administration or distribution of anabolic steroids);

(c)(xxiv) 2925.24 (tampering with drugs);

(c)(xxv) 2927.12 (ethnic intimidation);

DocuSign Envelope ID: 6B0AE150-68A0-4626-B0D5-7CCA065695AA Tier 4 Disqualifying Offenses (Five-Year Exclusion):

(d)(i) 2903.13 (assault);

(d)(ii) 2903.22 (menacing);

(d)(iii) 2907.09 (public indecency);

(d)(iv) 2907.24 (soliciting after positive human immunodeficiency virus test);

(d)(v) 2907.25 (prostitution);

(d)(vi) 2907.33 (deception to obtain matter harmful to juveniles);

(d)(vii) 2911.13 (breaking and entering);

(d)(viii) 2913.02 (theft);

(d)(ix) 2913.03 (unauthorized use of a vehicle);

(d)(x) 2913.04 (unauthorized use of property, computer, cable, or telecommunication property);

(d)(xi) 2913.05 (telecommunication fraud);

(d)(xii) 2913.11 (passing bad checks);

(d)(xiii) 2913.21 (misuse of credit cards);

(d)(xiv) 2913.31 (forgery, forging identification cards);

(d)(xv) 2913.32 (criminal simulation);

(d)(xvi) 2913.41 (defrauding a rental agency or hostelry);

(d)(xvii) 2913.42 (tampering with records);

(d)(xviii) 2913.43 (securing writings by deception);

(d)(xix) 2913.44 (personating an officer);

(d)(xx) 2913.441 (unlawful display of law enforcement emblem);

(d)(xxi) 2913.45 (defrauding creditors);

(d)(xxii) 2913.51 (receiving stolen property);

(d)(xxiii) 2919.12 (unlawful abortion);

(d)(xxiv) 2919.121 (unlawful abortion upon minor);

(d)(xxv) 2919.123 (unlawful distribution of an abortion-inducing drug);

(d)(xxvi) 2919.23 (interference with custody);

(d)(xxvii) 2919.24 (contributing to unruliness or delinquency of child);

(d)(xxviii) 2921.12 (tampering with evidence);

(d)(xxix) 2921.21 (compounding a crime);

(d)(xxx) 2921.24 (disclosure of confidential information);

(d)(xxxi) 2921.32 (obstructing justice);

(d)(xxxii) 2921.321 (assaulting/harassing police dog or horse/service animal);

(d)(xxxiii) 2921.51 (impersonation of peace officer);

(d)(xxxiv) 2925.09 (illegal administration, dispensing, distribution, manufacture, possession, selling, or using any dangerous veterinary drug);

(d)(xxxv) 2925.11 (drug possession other than a minor drug possession offense);

(d)(xxxvi) 2925.13 (permitting drug abuse);

(d)(xxxvii) 2925.22 (deception to obtain dangerous drugs);

(d)(xxxviii) 2925.23 (illegal processing of drug documents);

(d)(xxxix) 2925.36 (illegal dispensing of drug samples);

(d)(xl) 2925.55 (unlawful purchase of pseudoephedrine product);

(d)(xli) 2925.56 (unlawful sale of pseudoephedrine product); DocuSign Envelope ID: 6B0AE150-68A0-4626-B0D5-7CCA065695AA Authorization to Obtain Employment Background Report I have read the Disclosure Regarding Employment Background Report provided by United Disability Services (“COMPANY”) and this Authorization to Obtain Employment Background Report. By my signature below, I hereby consent to the preparation by Sterling Infosystems, Inc.

(“STERLING”), a consumer reporting agency located at 4511 Rockside Road, 4th Floor, Independence, OH 44131, 800-***-****, www.sterlingcheck.com, of background reports regarding me and the release of such reports to the COMPANY and its designated representatives, to assist the COMPANY in making an employment decision involving me at any time after receipt of this authorization and throughout my employment, to the extent permitted by law. To this end, I hereby authorize, without reservation, any state or federal law enforcement agency or court, educational institution, motor vehicle record agency, credit bureau or other information service bureau or data repository, or employer to furnish any and all information regarding me to STERLING and/or the COMPANY itself, and authorize STERLING to provide such information to the COMPANY. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original. I acknowledge receipt of a copy of the Consumer Financial Protection Bureau’s “A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT.”

Signature: Date:

First Name:

Full Middle Name:4782

Last Name:

Social Security Number: XXX-XX-

(Last 4 digits only)

Date of Birth / /XXXX

(Month/Day only)

DocuSign Envelope ID: 6B0AE150-68A0-4626-B0D5-7CCA065695AA 06-20

***-**-****

Michael

Alan

1955

Jones

5/12/2023

DocuSign Envelope ID: 6B0AE150-68A0-4626-B0D5-7CCA065695AA 5/12/2023

Michael Jones

Michael Jones

DocuSign Envelope ID: 6B0AE150-68A0-4626-B0D5-7CCA065695AA 5/12/2023

Michael Jones

Michael Jones

DocuSign Envelope ID: 6B0AE150-68A0-4626-B0D5-7CCA065695AA Michael Jones

5/12/2023

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