IN THE WAYNE COUNTY MUNICIPAL COURT

WAYNE COUNTY, OHIO

State of Ohio Case Number(s): __________________

Plaintiff ________________________________

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Vs.

___________________ Motion To/For: ___________________

(Print Name) Defendant ________________________________

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Date Signature

CERTIFICATE OF SERVICE

I hereby certify that a copy of this document was served upon the Wayne County Prosecutor on

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(Date)

□ Regular Mail □ Certified Mail □ Fax □ Hand Delivery

□ Other, explain: _________________________ ____________________ _____________________________

Date Signature