IN THE WAYNE COUNTY MUNICIPAL COURT

WAYNE COUNTY, OHIO

__________________ Case Number(s): __________________

(Print) Plaintiff

Vs.

___________________ Motion To/For: ___________________

(Print) Defendant ________________________________

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Date Signature

CERTIFICATE OF SERVICE

I hereby certify that a copy of this document was served upon ______________________________________ on

_________________________________ by: (Print)

(Date)

□ Regular Mail □ Certified Mail □ Fax □ Hand Delivery

□ Other, explain:________________________ ____________________ _____________________________

Date Signature