IN THE UNITED STATES DISTRICT COURT 

FOR THE SOUTHERN DISTRICT OF OHIO 

EASTERN DIVISION

UNITED STATES OF AMERICA,

 

 Plaintiff,

vs.

KARE MEDICAL TRANSPORT,

 Defendant.

) 

) 

) 

) 

)

)

)

)

)

)

CASE NO: 2:18-CV-933

COMPLAINT

Now comes the United States of America, by and through its legal representative, the 

United States Attorney for the Southern District of Ohio, and for its cause of action alleges:

1. Jurisdiction is founded on 28 U.S.C. §2462.

2. Defendant resides within this judicial district and division.

COUNT 1

3. On December 23, 2013, a Citation and Notification of Penalty was issued upon Defendant 

at 1000 Columbus Avenue, Marysville, OH 43040 regarding inspection site: 1000 Columbus 

Avenue, Marysville, OH 43040 in the amount of $33,847.97.

4. A true copy of each said citation is attached hereto, marked as "Exhibit A", and by this 

reference made a part hereof.

5. Although payment has been demanded, payment has not been made by the Defendant and 

the entire balance has become due and payable.

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1 Filed: 08/22/18 Page: 1 of 3 PAGEID #: 1
6. After all payments have been properly credited, the entire unpaid balance due and owing to 

Plaintiff from Defendant is $33,847.97 ($19,600.00 principal, $765.87 interest through June 21, 

2018, $4,497.26 penalty fee through June 21, 2018, $10.00 administrative fee, $7,959.40 DMS 

fees, and $1,015.44 DOJ fees), all of which is evidenced by the Certificate of Indebtedness which 

is attached hereto, marked as "Exhibit B", and by this reference made a part hereof.

COUNT 2

7. On June 11, 2014, a Citation and Notification of Penalty was issued upon Defendant at 

1000 Columbus Avenue, Marysville, OH 43040 regarding inspection site: 1000 Columbus 

Avenue, Marysville, OH 43040 in the amount of $26,572.19.

8. A true copy of each said citation is attached hereto, marked as "Exhibit C", and by this 

reference made a part hereof.

9. Although payment has been demanded, payment has not been made by the Defendant and 

the entire balance has become due and payable.

10. After all payments have been properly credited, the entire unpaid balance due and owing 

to Plaintiff from Defendant is $26,572.19 ($15,400.00 principal, $597.65 interest through June 21, 

2018, $3,508.88 penalty fee through June 21, 2018, $20.00 administrative fee, $6,248.49 DMS 

fees, and $797.17 DOJ fees), all of which is evidenced by the Certificate of Indebtedness which is 

attached hereto, marked as "Exhibit D", and by this reference made a part hereof.

COUNT 3

11. On May 12, 2006, Citation and Notification of Penalty was issued upon Defendant at 1000 

Columbus Avenue, Marysville, OH 43040 regarding inspection site: 1000 Columbus Avenue, 

Marysville, OH 43040 in the amount of $56,340.45.

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1 Filed: 08/22/18 Page: 2 of 3 PAGEID #: 2
12. A true copy of each said citation is attached hereto, marked as "Exhibit E", and by this 

reference made a part hereof.

13. Although payment has been demanded, payment has not been made by the Defendant and 

the entire balance has become due and payable.

14. After all payments have been properly credited, the entire unpaid balance due and owing 

to Plaintiff from Defendant is $56,340.45 ($32,670.00 principal, $1,267.86 interest through June 

21, 2018, $7,443.84 penalty fee through June 21, 2018, $20.00 administrative fee, $13,248.54 

DMS fees, and $1,690.21 DOJ fees), all of which is evidenced by the Certificate of Indebtedness 

which is attached hereto, marked as "Exhibit F", and by this reference made a part hereof.

WHEREFORE, Plaintiff prays for judgment against Defendant in the amount of 

$116,760.61 ($67,670.00 principal, $2631.38 interest through June 21, 2018, $15,449.98 penalty 

fee through June 21, 2018, $50.00 administrative fee, $27,456.43 DMS fees, and $3,502.82 DOJ 

fees), and for all further relief to which Plaintiff is entitled. 

Plaintiff further prays for its costs and for an award of postjudgment interest at the highest 

rate allowable by law, and for all further just and proper orders.

Respectfully submitted,

BENJAMIN C. GLASSMAN

United States Attorney

s/Bethany J. Hamilton

BETHANY J. HAMILTON (0075139)

Assistant United States Attorney

Attorney for Plaintiff

303 Marconi Boulevard, Suite 200

Columbus, Ohio 43215

Office: (614) 469-5715

Fax: (614) 469-5240

E-mail: Bethany.Hamilton@usdoj.gov

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1 Filed: 08/22/18 Page: 3 of 3 PAGEID #: 3
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and its successors

1000 Columbus Ave

Marysville, OH 43040

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Inspection Site:

1000 Columbus Ave

Marysville, OH 43040

7012 2210 0001 2080 2389

This Citation and Notification ofPenalty (this Citation) describes violations of the Ocoupational Safety and

Health Act of 1970. The penalty(ies) listed herein is (are) based on these violations. You must abate the

violations refered to in this Citation by the dates listed alrd pay the penalties proposed, unless within 15 working

days (excluding weekends and Federal holidays) from your receipt ofthis Citation and Notification ofPenalty

you either call to schedule an informal conference (see paragraph below) or you mail a notice of contest to

the U.S. Department oflabor Area Office at the address shown above. Please refer to the enclosed booklet

(OSHA 3000) which outlines youl rights and responsibilities and which should be read in conjunction with this

form. Issuancc ofthis Citetion does not constitute a finding that a violation ofthe Act has occurred unless tl.rere

is a failure to contest as provided foi in tbe Aot or, if contested, unless this Citation is afflmed by the Review

Commission or a coud.

Posting - The law requires that a copy ofthis Citation and Notification of Penalty be posted irmuediately in a

pr.ominent place at or near the location ofthe violation(s) oited herein, or, if it is not practicable because ofthe

nature of the employe/s operations, where it will be readily observable by all affected employees. This Citation

must remain posied until the violation(s) cited herein has (have) been abated, or for 3 working days (exoluding

weekonds and Federal holidays), rvhichever is longer'

Informal COnferenCe - An informal conference is not required. However, if you wish to have such a

conference you may request one with the Area Director during the 15 working day contest period. Ddring such

an informal conference you may present any evidence or views wltich you believe would supPort an adjustment

to the citation(s) and/or penalty(ies).

osIlA-2

GOVERNIIENT

EXHIBIT

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Cihtion aDd Notificadon of P.nllty Pr8. I of 13

DELIVERY

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-1 Filed: 08/22/18 Page: 1 of 9 PAGEID #: 4
Ifyou are considering a request for an informal oonference to discuss any issues related to this Citation and

Notification of Penalty, you must tske care to schedule it early enough to allow time to contest after the informal

conference, sbould you decide to do so. Please keep in mind that a written letter of intent to contest must be

submitted to tle Area D eotor within l5 working days ofyour receipt of this Citation. The running ofthis

contest period is not intenupted by an informal conference;

Ifyou deoide to request an informal conference, please complete, remove and post the Notic€ to Employebs next

to this Citation and Notifroation ofPenalty as soon ss the time, date, and place ofthe informal conference have

been determined. Be sure to bring to the conference any and all supporting documentation of oxisting conditions

as well as any abatement steps taken thus far. Ifconditions warant, we can enter into an informal settlement

agreement which amicably resolves this matter without litigation or contest.

Right to Contest - You have the dght to contest this Citation and Notification of Penalty. You may contest

all citation items or only individual items. You may also contest proposed penalties and/or abatement dates

without contesting the underlying violations. Ilnless vou inform the Area Director in ritins that vou intend

to contest the citatlon(s) and/or prooosed oenaltvfies ) within 15 workins davs aft€r the citation(s)

and the nronosed nenal tes) will become a final order of the OccuDalioral and Ilealth Review

Commission and may not be reviewed bv any court or asency.

httos://www.oav. sov/pay gov/foms/fo nnlnstance.html? Formld=S3 090334.

You will be required to enter your inspection number when making the payment. Pqnnents can be made by

credit card or Automated Cleaxing House (AC[I) using your banking information. Payments of $50,000 or more

require a Transaction ID, and also must be paid using ACH. If you require a Transaction ID, please contact the

OSHA Debt Conecd onTemt st (202) 693-2170.

OSIIA does not agree to any restrictions or conditions or endorsements put on any check, money order, or

elecfuonio p&yment for less than the full amount duq and will process tho payments as ifthese restuictions or

conditions do not exist.

Notification of Corrective Action - For each violation which you do not contest, you must provide

flbdterrred certilicatlon to the Area Director of the bSIIA office issuing lhe citation and identified above, This

abatement certification is to be provided by letter within 10 calendai days after each abatement date, Abatement

certification inoludes the date and method ofabatement. Ifthe citation indicates that the yiolation was corrected

during the inspection, no abatement certification is required for that item. The abatement c€rtification letter must

be posted at the location where the violation appeared and the corective action took place or employees mdst

otherwise be effectively informed about abatement activities. A sample abatement certification letter is enclosed

with this Citation. In addition, where the citation indicates thal abdtement docratunidion is necessary, evidence

ofthe purchase or repair ofequipment, photographs or video, receipts, training records, etc., veri$ing that

abatement has occurred is required to be provided to tho Area Director.

Citation and Notifi cation olPeoally Page 2 of l3 osHA-2

I

Penalty Payment - Penalties are due within 15 working days ofreceipt ofthis notification unless contested.

(See the enclosed booklet and the additional information provided related to the Debt Collection Act of 1982.)

Ma-ke your check or money order payable to 'DOL-OSHA". Please indicate the Inspection Number on the

remitlance. You can also make your payment elechonically on www.pay.gov. On the leftside of the pay.gov

homepago, you will see an option to Search Publio Forms. Tlpe "OSEA" and click Go. From the results, click

on OSEA Penalty Peyment Form. The direct link is:

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-1 Filed: 08/22/18 Page: 2 of 9 PAGEID #: 5
Employer Discrimination Unlawful - The law prohibits discrimination by an employer against an

employee for filing a complaint or for exercising any rights under this Act. An employee who believes that

he/she has been discriminated against may file a complaint no later than 30 days after the discrimination

oooured with the U.S. Department of Labor Area Office at the address shown above.

Employer Rights and Responsibilities - The enclosed booklet (OSIIA 3000) outlines additional

omployer righs and responsibilities and should be read in conjunction with this notification.

Notice to Employees - The law gives an employee or his/}er representatiye the opportunity to object to any

abatement dale set for a violation if he/she believes the date to bo unreasonable. The contest must be mailed to

the U.S. Department oflabor Area Offrce at the address shown above and postmarked within l5 working days

(excluding weekends and Federal holidays) of the receipt by the employer ofthis Citation and Notification of

Penalty.

Citalion ard Notitication of Penalty Pagc 3 of l3 osHA.2

Inspection Activity Data - You should be aware that OSHA publishes information on its inspection and

citation activity on the Internet under the provisions ofthe Electronic Freodom oflnformation Act. The

information related to these alleged violations will be posted when our system indicates that you have received

tiis citation. You are encouraged to review the information conceming your establishment at www.osha.gov, If

you have any dispute with the acouracy ofthe information displayed, please contact this office.

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-1 Filed: 08/22/18 Page: 3 of 9 PAGEID #: 6
U,S, Department of Labor Inspection Number: 953085

Occupational Safety and Health Administration Inspection Drte(s): 12/23/2013 - 1212412013

Issuance Date: 03/0512014

Company Name: Kare Medical Transport

Inspection Site: 1000 Columbus Ave, Marysville, OH 43040

Citation 1 Item I Type of Violation: Sefious

29 CFR 1910.305(g)(1)(iv): Unless specifically permitted otherwise in paragraph (g)(1)(ii) ofthis

section, flexible cords and cables may not be used:

29 CFR 1910,305(9)(1)(iv)(A): As a substitute for the lixed wiring ofa structure:

a. In the Carage Area at the workplacc, the employer used a flcxible cord to zupply power to an

overhead garage door opener.

ABATSMENT DOCI,]MEI{TATION REQUIRED FOR THIS ITEM

Date By Which Violation Must be Abated:

Proposed Penalty:

Sec pag.s I through 4 ofthis Citation and Notification ofPenalty for information on cftploycr and .mplor'€e righls and responsibilities.

Citstion and Notificstion ofPcnalty Pagc 6 of ll OSHA-2

0312512014

$2800.00

Citation and Notification of Penaltv

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-1 Filed: 08/22/18 Page: 4 of 9 PAGEID #: 7
U.S. Department of Labor Inspection Number: 953085

occupationat safety and Health Administration Inspection Date(s) z 1212312013 - 1212412013

Issuance Date: 0310512014

Citation and Notification of Pcnllty

Company Name: Kare Medical Transport

Inspcclion Site: 1000 Columbus Ave, Marysville, OH 43040

Citation Item 2 Tlpe of Violation: SefiOUS

29 CFR 1910.1030(c)(l )(i): Each employer having an employee(s) with occupational exposure as

defined by paragraph (b) ofthis section shall establish a written Exposure Control Plan designed to

eliminate or minimize employee exposure:

a. At the workplace, the employer did not establish a wdtten Exposure Control Plan for employee with

occupational exposure to blood. These employees provided medical services.

ABATEMENT DOCUMENTATION REQUIRED FOR THIS ITEM

Date By Which Violation Must be Abated:

Proposed Penalty:

Sec pagca I through 4 ofthis Cilation End Notification ofPcnally for inlormation on cmploycr and onploycc riShts .nd rcsponsibilities.

Ci(ltion and Noliffcstion of Pen.liy Pagc 7 of 13 OSHA-2

03125120t4

$4900.00

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-1 Filed: 08/22/18 Page: 5 of 9 PAGEID #: 8
U.S. Department of Labor Inspection Number: 953085

Occupational Safety and Health Adminishation Inspection Date(s\t 1212312013 - 1212412013

Issuance Drte: 0310512014

Citation rnd Notification of Penaltv

Company Name: Kare Medical Transport

Inspection Site: 1000 Columbus Ave, Marysville, OH 43040

Citation I Item 3 'llpe of Violation: SeriOuS

29 CFR 1910.1030(0(1Xi): The employer shall make available the hepatitis B vaccine and vaccination

series to all employees who have occupational exposure, and post-exposure evaluation and follow-up to

all employees who have had an exposure incident:

a. At the workplace, the employer did not make available the hepatitis B vaccine and vaccination series

to all employees who have occupational exposure,

ABATEMENT DOCUMENTATION REQUIRED FOR THIS ITEM

Date By Which Violation Must be Abated:

Proposed Penalty:

Scc psga! I lhrough 4 of ttlis Citsdon and Notificatio, of P.n6lt for information on employo ,nd employcc riglts and rospons ibilitica.

ciration and Norific.tion ofPcnalty Pagc 8 ofl3 osHA'2

04109120t4

$4900.00

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-1 Filed: 08/22/18 Page: 6 of 9 PAGEID #: 9
U.S,DepartmentofLabor InspectlonNumber:953085

Occupational Safety and Heatth Administration Inspection Date(s): l2/23D013 ' 12124/2013

Issuance Date: 03/0512014

Citation and Notification of Penaltv

Company Name: Kare Medical Transport

Inspection Site: 1000 Columbus Ave, Marysville, OH 43040

Citation 1 Item 4 Type of Violation: Serious

29 CFR 1910.1030(gX2Xi): The employer shall train each employee witl occupational exposure in

accordance with the requirements of this sestion. Such training must be provided at no cost to the

employee and during working hours. The employer shall institute a training program and ensure

employee participation in the program:

a. At the workplace, the employer did not ensure that employees with occupational exposue to

bloodborne pathogens received training in accordance with the requirements ofthis section.

ABATNMENT DOCUMENTATION REQUIRED FOR THIS ITEM

Date By Which Violation Must be Abated:

Proposed Penalty:

04109t20t4

$4900.00

Sca pagas I through 4 of tnis Citltion and Notilication ofPcoalty for inforrnation on .mployel ard cmplo}le rights ard raspoosibilities.

Citatioa ard Notificaliofl of P.natty Poge 9 of 13 OSHA-2

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-1 Filed: 08/22/18 Page: 7 of 9 PAGEID #: 10
U.S. Department of Labor Inspectlon Number: 953085

Occupational Safety and Heatth Administration Inspection Date(s); 1212312013 - 12/2412013

Issuance Drte: 03 105120'14

Company Name: Kare Medical Transport

Inspection Site: 1000 Columbus Ave, Marysville, OH 43040

29 CFR 1910.1200(e)(1): Employers shall develop, implement, and maintain at each workplace, a

written hazard communication program which at least describes how the criteria specified in

paragraphs (0, (g), *d (h) ofthis section for labels and other forms of warning, material safety data

sheets, and employee information and training will be met:

a. At the workplace, the employer did not develop, implement, and maintain a written hazard

communication progam. Employees were exposed to hazardous chemicals including, but not limited to

diesel fuel.

ABATEMENT DOCUMENTATION REQUIRED FOR THIS ITEM

Date By Which Violation Must be Abated:

Proposed Penalty:

04109120t4

$2100.00

Sce pages I through 4 olthis Citation and Notjfication ofPenalty for information on€mploy€r and €mployee rights and respofisibiliti€s.

Citalion and Notilicalion ofPenatty Pa8. l0 of 13 OSHA.2

Citation and Notification of Penalty

Citation 1 Item 5 Type of Violation: SeriouS

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-1 Filed: 08/22/18 Page: 8 of 9 PAGEID #: 11
U.S. Department of Labor Inspection Number: 953085

OccupatiJnal Safety and Health Administratl6l Inspection Date($: 12123/20"13 - 1212412013

Issu&nce Date: 03 105 120 1 4

Citation and Notification of P€naltv

Citation 2 Item I rype of viotation: Other-than-Serious

29 CFR 1904.29(a): The ernployer did not use an OSHA300,301 and 300A Form or equivalent:

Located at Kare Medical Transport in Marysville, Ohio:

a. At the workplace, the employer was not maintaining OSHA 300, 301, and 300Aforms for 2013.

ABATEMENT DOCUMENTATION REQUIRED FOR THIS ITEM

Date By Which Violation Must be Abated:

Proposed Penalty:

04109120t4

$0.00

Debo

Area Di

Sc. pagcs I through 4 of dlis Citation ard Notificalion ofPcnalty for information ot amploycr ard cmploye-€ tiShts and rcsponsibililies.

Cilation 6nd Notifioatioo ofPcnalty Paee ll of13 OSIIA'2

ZIubrly

r

Company Name: Kare Medical Transport

Inspection Site: 1000 Columbus Ave, Marysville, OH 43040

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-1 Filed: 08/22/18 Page: 9 of 9 PAGEID #: 12
ACTING ON BEHALF OF

U.S. Department of Labor, Occupational Safety & Health Administration

CERTIFICATE OF INDEBTEDNESS

Debtor Name(s) and Address(es):

Kare Medical Transport

c/o Jason Keeran

1000 Columbus Ave.

Marysville, OH 43040

RE: Treasury Claim TRFM2014301505

I certiry that the U.S. Department ofLabor, Occupational Safety & Health Administrarion (OSIIA)

records show that the debtor named above is indebted to the United States in the amount stated as

follows:

Principal:

Interest through 06/21 / 18* :

Penalty fee through 06/21/18*:

Admin fee:

DMS fees:

DOJ fees:

s 19,600.00 $ 76s.87

g 4,497.26 $ 10.00

$ 7,959.40

$ 1,01s.44

(pursuant to 3l U.S.C. 3717(e) and 3?l t(gX6), (7); 3l C.F.R. 285.12(j) and 3l C.F.R. 901.1(0; and 28 U.S.C. 527, oote)

TOTAL debt owed as of06/21118: $33,847.97

*NOTE: Per the creditor agency, once the debt is referred to Fiscal Service, interest continues to accrue at

the rate of 102 per annum as well as a penalty at the rate of 602 per annum.

This debt reportedly arose in connection with the numerous workplace safety violations ofthe

Occupational Safety and Health Act of 1970 (29 U.S.C. 650/651 et seq.) and OSHA regulations (29

C.F.R. 1926), as noted during the original December 2013 OSHA inspections ofthe debtor's work site at

1000 Columbus Ave, Marysville, OH 43040.

CERTTFICATION: Pursuant to 28 USC ss. 1746, I certifo under penalty of perjury that the foregoing

is true and correct to the best ofmy knowledge and beliefbased upon information provided by the U.s.

Department ofLabor, Occupational Safety & Health Administration.

X ,1'-L'L* zi!-*-c--

sigh.d t). .Ashleish N. Edtund.

Ashleigh Edmonds

Financial Program Specialist

U.S. Department of the Treasury

Bureau ofthe Fiscal Service

3

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GOVERNMENT

EXHIBIT b

U.S. DEPARTMENT OF THE TREASURY

BUREAU OF THE FISCAL SERVICE

WASHINGTON , D .C, 20227

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-2 Filed: 08/22/18 Page: 1 of 1 PAGEID #: 13
U,S. Department of Labor

Occupational Safety and Health Adminishation

200 N. High Sheet

Room 620

Columbus, OH 43215

Phone: 6i4-469-5582 Fa* 614469-6791

Citation and Notification of Penalty

To:

Kare Medical Transport

and its successors

1000 Columbu.s Ave

Marywille, OH 43 040

Inspection Number: 981 142

Inspection Date(s): 0611U2014 - 06/11.D014

Issuance Date: 06/2312014

7012 2210 000t 1866 8270

This Citation and Notification ofPenalty (this Citation) describes violations of tho Occupational Safety and

Health Act of 1970. Tho pena$(ies) listed herein is (are) based on these violations. You must abate tfre

violations referred to in this Citation by ths dates listed and pay th6 penalties proposed, unless within 15 working

days (excluding weokends and Federal holidays) from your receipt ofthis Citstion and Notification ofPenalty

you either c-all to schedule an informal conferrnce (see paragraph below) or you mail a notice of contest to

theU.S. Departrnent oflabor Area Office at the address shown abovo. Please refer to the enclosed booklet

(OSHA 3000) whioh outlines your rights and responsibilities aad which should be read in conjunction with this

form. Issuance ofthis Cit&tion does not constitute a finding that a violation ofthsAct has ocrcurred unless there

is a faiiuro to contest as prorridod for in the Act or, if contested, unless this Citation is affirmed by tlo Review

Commission or a court.

Posting - The law requires that a copy of this Citation and Notification ofPenalty be posted immediately in a

prominent place at or near dre location oftle violation(s) cited hereio, or, if it is not practicable beceuse of the

nature ofthe employer's oporalions, where it will be readily observable by all affected employees. This Citation

must remain posted until the violation(s) cited herein has (have) been abate4 or for 3 working days (excluding

weekends and Federal holidays), whichever is longer.

Informal Conference - An informal confersnco is not required. However, ifyou wish to have such a

conference you may request one with the Area Director during tho 1 5 working day contest period. During such

an informal conference you may present any evidence or views which you believe would support an adjustment

to the citation(s) and/or penalty(ies).

OOVERNiIENT

EXHIBIT

c

Cihtiod and Notificalion of Pcnalty Psgc I oft

Inspection Site:

1000 Columbus Ave

Marywille, OH 43040

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-3 Filed: 08/22/18 Page: 1 of 4 PAGEID #: 14
Ifyou are considering a roquest for an informal conference to discuss any issues relatod to this Citation and

Notification of Penalty, you must take care to schedule it early enough to a11ow time to contest after the informal

conference, should you decide to do so. Please keep in mind that a written letter of intont to contest must be

submitted to tho Area Director within 15 working days ofyour receipt of this Citation. The running ofthis

contest period is not intemrpted by an informal conference.

If you deoide to request an informal conferenco, please completo, remove and post the Notice to Employees next

to this Citation and Notification ofPenalty as soon ai the time, date, and piace ofthe informal conference havo

beon determined. B€ sure to bring to tho oonforence any and all supporting documentation of existing conditions

as well as any abatement stops taken thus far. If conditions warrant, we can enter into an informal settlement

agreement which amicably resolves this matter without litigation or contes't.

Right to Contest - You have the right to contest this Citation and Notilication ofPenalty. You may contest

al1 citation items or only ildividual items. You may also oontest proposed penalties and/or abatement dates

without contesting the uaderlying violations. Unless vou inform the Area Director in writine that vou intend

to contest the citation(s) and/or rrooosed penaltvfies) within 15 workine davs aiter rcceiot. the citation(s)

and the proposed penalty(ies) will become a final order of the Occupational Safe8 and EeEIth Review

o .html F' 14.

You will be required to enter your inspection number when making the payment. Payments can be made by

credit card or Automated Clearing House (ACII) using your banking information. Pa)rments of $50,000 or more

require a Transaction ID, and also must be paid using ACH. Ifyou require a Transaction ID, please contact the

OSIIA Debt Collection Team at (202) 693-217 0.

OSIIA does not agree to any res'hictions or conditions or endorsements put on any checlq money ordet or

electronic pa].ment for less thaa the full arrount due, and will process tho paymeots as iftlese resbictiols or

coflditions do not exist.

Notification of Corrective Action - For eaoh violation which you do not contest, you must provide

abalement celtfuatlon to the Area Director of the OSHA office issuilg the oitation and identified above. This

abatement certification is to bo provided by letler within 10 calendar days after each abatement date. Abatement

certification inoludes the date aad method ofabatement. If the citetion indicates that tte violation was corrected

during the inspection, no abatsment c€rtification is required for that item. The abatemeat certification letter must

be posted at the location where the violalion appeared and the corrective action took place or employees must

otherwise be effectively informed about abatement activitios. A samplo abatement certification letter is enclosed

with this Citation. In additioq where the citation indicates thal abalenant alocanentation is necessary, evidence

oftho purchase or repair ofequipmen! photographs or video, receipts, tuaining records, eto., verifoing that.

abatoment has occurred is requhed to be provided to the Area Director.

Citdion ,rd Notification ofPenalty osHA-2

Commission and mav not tre reviewed bv anv court or asency.

Penalty Palment - Penalties are due within 15 working days of receipt of this noffication unless contested.

(See the enclosed booklet ard the additional information provided related td the Debt Collection Act of 1982.)

Make your check or money order payable to "DOL-OSHA". Please indicate tho Inspection Numbor on the

remittance. You can also mako your paymotrt electonically on www.pay,gov. On the left side of the pay.gov

homepagq you will see an option to Search Public Forms. Tlpe .OSIIA" ald click Go. From the results, click

on OgEA-E9Ed&-EgMg4|EsIE. The direct link is:

Psgo 2 of 8

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-3 Filed: 08/22/18 Page: 2 of 4 PAGEID #: 15
Employer Discrimination Unlawful - The Iaw prohibits discrimination by ar ernployer against an

employee for filing a complaint or for exercising any rights under this Act. An employee who believes that

he/she has been discriminated against may file a complaint uo later than 30 days after the discrimination

occurred with the U.S. Deperhnent ofl-abor Area Office at the address shown above.

Employer Rights and Responsibilities - The enclosed booklet (OSIIA 3000) outlines additional

employer rights and responsibilities and should be read in conjunction with this notification.

Notice to Employees - The 1aw gives a:r employee or his/her ropresentative tho opportunity to object to any

abstemont date set for a violation ifhe/she believes tho date to be umeasonable. The contest must be mailed to

theU.S. Depar0nent ofl,abor Area Office at the address shown above aad postmarked within 15 working days

(excluding weekends and Federal holidays) ofthe receipt by the employer of this Citation and Notification of

Penalty.

Iuspection Activity Data - You should be aware that OSIIA publishes information on its inspection and

citation activity on the Intemet under the provisions ofthe Electronic I'reedom of Infomration Act. The

infonnation related to these alleged violations will be posted when our system indicates that you have received

this citation. You are encouraged to review the information conceming your establishment at www.osha,gov If

you have any dispute with the accuraoy ofthe bfomration displayed, please contact this ofiice.

Citarion and Notif crtion of Ponalty Page 3 ol8 osHA-2

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-3 Filed: 08/22/18 Page: 3 of 4 PAGEID #: 16
-

Citation and Notification of Pen altv

Company Nrme: Kare Medical Transport

Inspection Site: 1000 Columbus Ave, Marysvillo, OH 43040

U.S. Department of Labor Inspection Numbet 981142

Occupati6nal Safety aad Health Administation InsPection Date(s): 06/112014 - 06lllD0l4

I$usnce Date: 0612312014

Citation 1 Item 1 Tlpe of Violation: Repeat

29 CFR 1910.305(9)(1)(iv): Unless specifically pernitted otherwise in paragraph (g)(l)(ii) ofthis

sectiorg flexible cords a:rd cables may not be used:

29 CF'R 1910.305(gXt)(iv)(e): As a substitute for the fixed wiring of a structue:

a. In the garage area connected to the dispatch offrce, the employer used a flexible cord to supply

wiring to a garage door opener.

b. ln the garage area connected to the dispatch office, the employer used a flexible cord to supply

electricity to plug into the ambula:rce receptacle for charging the on-board electronics.

c. In the garage area connected to the living quarters, the employer used a flexible cord to supply

electricity to plug into the ambulance receptacle for charging the on-board electronics.

Kare Medical tansport was previously cited for a violation of this occupational safety and

health standard or ih equivalent standard 29 CFR 1910.305(9)(1)(iv), which was contained in

OSIIA inspection number 9530E5, citation number 1, item number 1 and was allirmed as a final

order on March 28, 2014, with respect to the workplace located at 1000 Columbus Avenue in

Marysville,Ohio 43040.

ABATEMENT DOCIftTENTATION REQUIRED FOR THIS ITEM

Date By Which Violation Must be Abated:

Proposed Penalty:

0712612014

$15400.00

borah J. Zubaty

Area Direclor

Scc psgr3 t through 4 ofthis Cit tion and Notifcarion ofPcoalg for informatioo on Glnploycr end .mplo],oe dgha and rcsponsibilitiB.

Citdion dd Nolificdion ofP.rulty Pag.6 of8 OSH.A-2

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-3 Filed: 08/22/18 Page: 4 of 4 PAGEID #: 17
U.S. DEPARTMENT OF THE TREASURY

BUREAU OF THE FISCAL SERVICE

WASHINGTON,D.C,20227

Debtor Name(s) and Address(es):

Kare Medical Transport

c/o Jason Keeran

1000 Columbus Ave.

Marysville, OH 43040

RE: Treasury Claim TRFM2Ol 5034530

I certi6/ that the U.S. Department ofLabor, Occupational Safety & Health Administration (OSHA)

records show that the debtor named above is indebted to the United States in the amount stated as

follows:

Principal:

Interest through 06/21 118* :

Penalty fee throu gh 06/21/18*:

Admin fee:

DMS fees:

DOJ fees:

(pursuant to 3l U.S.C. 3717(e) and 371 l(s)(6), (7); 3l C.F.R. 285.12(.1) and 3l C.F.R. 901.1(f); and 28 U.S.C. 527, note)

TOTAL debt owed as of 06/21118: 526,572,19

*NOTE: Per the creditor agency, once the debt is referred to Fiscal Service, interest continues to accrue at

the rate of l% per annum as well as a penalty at the rate of 60lo per annum.

This debt reportedly arose in connection with the numerous workplace safety violations ofthe

Occupational Safety and Health Act of 1970 (29 U.S.C. 650/651 et seq.) and OSHA regulations (29

C.F.R. 1926), as noted during the June 2014 inspections ofthe debtor's work site at 1000 Columbus Ave

Marysville, OH 43040.

CERTIFICATION: Pursuant to 28 USC ss. 1746, I certiff under penalty ofperjury that the foregoing

is true and correct to the best ofmy knowledge and beliefbased upon information provided by the U.S.

Department ofLabor, Occupational Safety & Health Administration.

x z*-=tt"+

sasn.d 61. ashr.ish N. Edtu^ds

Ashleigh Edmonds

Financial Program Specialist

U.S. Department of the Treasury

Bureau ofthe Fiscal Service

"":ilT$f D

NT

ACTING ON BEHALF OF

U.S. Department of Labor, Occupational Safety & Health Administration

CERTIFICATE OF INDEBTEDNESS

$15,400.00 $ 597.65

$ 3,508.88

s 20.00

$ 6,248.49

s 797.t7

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-4 Filed: 08/22/18 Page: 1 of 1 PAGEID #: 18
U.S. Department of Labor

Oooupational Safety and Health Administration

200 N. High Sheet

Room 620

Columbus, OH 43215

Phono: 614-469-5582 F ax: 674-469 -679 I

ET

EEE

To:

Kare Medical Transport

and its successors

1000 Columbus Ave

Marysville, OH 43040

Original Inspection Number: 953085

Original Inspection Dzte: l2l23l?013 - 12/24/2013

fnspection Number: 981142

Inspection Date(s): 0611.1D014 - 06/11D014

Issu&nce I)ate: 06 123 l20l 4

Inspection Site:

1000 Columbus Ave

Marysville, OH 43040

70t2.2210 0001 1866 8270

After tle original inspection, a Citation(s) was issued to you in aocordance with tle provisions oftho

Oocupational Safety and Health Act of 1970 (the Aot), notifring you of certain violations of the Act and the dates

by which they were to be abated. Based upon re-inspection, it is alleged that you have fuiled to abate the

violation(s) listed below within the time prescribed, and the following additional penalties are proposed. The

additional penalty is computed by multiplying a daily penalty times the number of days the violation(s) remainod

unabated- You are to notiry the Arca Director in writing of the date and nature of the correctivo aotion taken. If

you do not abate the violation(s), further penalties may bo proposed and other enforcement action to oompel

abatement may be taken under section I l(b) of the Act.

Notification of Corrective Action - For ggg! violation which you do not contest, you are roquired by 29 CFR

1903.19 to submit an Abatement Certification to tle Area Director of OSIIA office iszuing tho citation and

identified above. The certification ggg! be sent by you within 10 celendar davs ofthe abatement date indicated

on the citation. For Willful and Repeat violations, documents (exanples: photos, copies ofreceipts, training

records, etc,) demonshating that abatement is complete must accompany the oertifioation. Where the citation is

classified as Serious and the citations states the abatement documentation is requirod, documents such as tlose

described above are required to be submitted along with tie abat€ment oertificato. Ifthe citation indicates that

the violation was corrected during the inspection, no abatement certificate is required for that item.

All abatenrent veritrcatlon documents must contain the following information: 1) Your narne aad address;

2) the inspection number (found on the ftont page); 3) tho citation and oitation item numbe(s) to which the

submission relates; 4) a statement that the information is accurato; Q the signahrre oftho employer or employer's

authorized representative; O the date tho hazard was corrected; 7) a brief statement of how the hazard was

corected; and 8) a statoment that affected employees and lheir representatives have been infonned ofthe

abatement.

GOVERNMENT

EXHIEIT

E

a

t!I

3

t

Pagc I of L0 ost.IA-28

Notification of Failure to AbateAlleged Violations

Notifi carion otFsilurc to Aba(cAllcged Violations

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-5 Filed: 08/22/18 Page: 1 of 6 PAGEID #: 19
The law also requires a copy ofall abatement verification documents, required by 29 CFR 1903. t9 to be sent to

OSIIA, also be posted at the location where the violation appeared and the correofive action took place.

You are fi.rther notified that you must pay th€ ADDITIONAL PENALrY unless you inform the Area Director in

$,riting that you intend to contest the Notification or the Additional Penatty within 15 working days (oxcluding

weekends and Fedetal holidays) from your receipt of this notification. Ifyou do not contost within 15 working

days after receipt the Notification ald tie additional penalties will become the final order oftho Occupational

Safety and Health Rwiow Commission and may not be reviewed by any court or agency. Issuancc ofttris

Notification does not constihrte a finding that a violation ofthe Act has occuned unless there is a failure to

contest as provided for in tho Aot or, if contested, unless the Notification is affrmed by the Rwiew Commission

Make your check or money order payable to 'DOL-OSHA". Plsase indicate the Inspection Number on the

remittance.You can also make your payment electronioaily on www.pay.gov On the left side ofthe pay.gov

homepage, you will seo a:r option to Search Public Fonns. Type "OSEA" and click Go. From tle results, cliok

on (JSHA Penalty Pavment Form. The direct link is:

/form s/form Instan ce. h FormId:5309

You will be required to enter your inspection number s,hen making the payment. Payments can be made by

credit card orAutomated Clearing House (ACII) using your bad<ing information. Payments of $50,000 or more

require a Transaction ID, and also must be paid using ACH. Ifyou require a Transaction ID, please oontact tho

OSIIA Debt Collecti orTe*t at Q02) 693-2170.

OSHA does not agree to iny reshictions or conditiors or ondorsements put on any check, money order, br

electonic payment for less than the fuIl amount due, and will process the payments as if these restrictions or

conditions do not exist.

lnspection Activity Data - You should bo aware that OSIIA publishes information on its inspection and citation

activity on the krtemet under the provisions of tho Electronic Freedom of Information Aot. The information

related to ttrese alleged violations will bo posted when our system indicates that you have reoeived this citation.

You are encouraged to review the infomation conoerning your establishment at www.osha.eov. Ifyou havo any

dispute with the accuraoy ofthe information displayed, please contaot this office.

Notiication of Failurc to Abatc AllcScd \rioldions Pagc 2 of l0 OSHA.2B

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-5 Filed: 08/22/18 Page: 2 of 6 PAGEID #: 20
-

U.S. Department of Labor

Occupational Safety and Health Administration

Notification of Failure to Abate Alleged Violation

Original [nspection: 953085 Inspection Numberz 981142

Original Inspection Dates: 1212312013 - 12124/2013 Inspection Date(s): 06/1112014 - 0611112014

Issuance Date: 06/2312014

Company Name: Kare Medical Transport

Inspection Site: 1000 Columbus Ave, Marysville, OH 43040

29 CFR 1 910.103 0(c)( 1)(i): Each employer having an employee(s) with occupational exposure as

defined by paragraph (b) of this section shall estabtsh a written Exposue Control Plan designed to

eliminate or minimize employee exposure:

a. At the workplace, the employer did not establish a written Exposure Control PIan for employee with

occupational exposure to blood. These employees provided medical services.

Additional Penalty: $ 20000.00

Notification of Failur. to Abalc Allegcd Violatioff Psge 5 oft0 OSHA-2B

Citation I ltem 2

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-5 Filed: 08/22/18 Page: 3 of 6 PAGEID #: 21
U.S. Department of Labor

Occupational Safety and HealthAdministration

Notification of Failure to Abate Alleged Violation

Original Inspection: 953085 Inspection Number: 981142

original Inspection Dates: l2l23l2ol3 - 12124/2013 Inspection Date(s): 0611112014 - 06111D014

. 

Issuance Date: 06/2312014

Company Name: Kare Medical Transport

Inspection Site; 1000 Columbus Ave, Marysville, OH 43040

Citation 1 Item 3

29 CFR 1910.1030(0(t)(i): The employer shall make available the hepatitis B vaccine and vaccination

series to all employees who have occupational exposure, and post-exposure evaluation and follow-up to

all employees who have had an exposure inoident:

a- At the workplace, the employer had not made available the hepatitis B vaccine and vaccination

series to all employees who had occupational exposure.

Additional Penalty: $ 4900.00

Notification of Failurc !o Abato Allcged Violations PBBo 6 of l0 OSHA.2B

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-5 Filed: 08/22/18 Page: 4 of 6 PAGEID #: 22
U.S. Department of Labor

Oocupational Safety and HealthAdministration

Notilication of Failure to Abate Allcged Violation

Citation 1 Item 4

29 CFR 1910.1030(g)(2)(i): The employet shall train each employee with occupational exposure in

accordance with the requirements of this section. Such training must be provided at no cost to the

employee and during workilg hours. The employer sha1l institute a training prograrn and ensure

employee participation in the program:

a. At the workplace, the employer had not ensured that employees with occupational exposure to

bloodbome pathogens received training in accordance with the requirements of this section

Additional Penalty: $ 4900.00

Citation 1 Item 5

29 CFR 1910.1200(e)(1): Employers shall develop, implement, and maintain at each workplace, a

writlen hazard communication program which at least describes how the criteria specified in

paragraphs (f), (g), and (h) ofthis section for labels and other forms ofwarning, material safety data

sheets, and employee information and training will be met, and which also includes the following:

a- At the workplace, the employer had not developed, implemented, and maintafued a vnitten hazard

communication program. Employees were exposed to hazardous chemicals, including (but not limited

to) diesel fuel, transmission fluid, power steering fluid, brake fluid and coolaot.

Additional Penalty: $ 2100.00

Noti.fic{lion ol Fsilu.e to Abate Alleged Molations Pago 7 of 10 OSHA-zB

Original Inspection: 953085 Inspection Numbert 9S1L142

Original Inspection Dates: 12/2312013 - 1212412013 Inspection Date(s): 06/11/2014 - 06/1112014

Issuance Date: 06 123 D0l4

Company Name: Kare Medical Transport

Inspection Site: 1000 Columbus Ave, Marysville, OH 43040

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-5 Filed: 08/22/18 Page: 5 of 6 PAGEID #: 23
U.S. Department of Labor

Occupational Safety and Health Administration

Notification of Failure to Abate Alleged Violation

Original Inspection: 953085 Inspection Numberz 9El'142

Original Inspection Dates: 1212312013 - 1212412013 Inspection Date(s)z 0611112014 - 0611112014

Issuance D atez 06 I 23 120 I 4

Company Name: Kare Medical Transport

Inspection Site: 1000 Columbus Ave, Marysville, OH 43040

Citation 2 Item 1

29 CFR i 904.29(a): The emFloyer did not use an OSHA 300, 301 and 300A Form or equivalent:

Located at Kare Medical Transport in Marysville, Ohio:

a. At the workplace, the employer was not maintaining OSHA 300,301, and 3004' forms for 2013

a,:.d2014,

Additional Penalty: $ 770.00

eborah .T. Zubatv

Area Director

Notififftion ofFsilure to Abal Allcgcd Violatiofls Pagc 8 of L0 osHA-28

lEa l.:;

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-5 Filed: 08/22/18 Page: 6 of 6 PAGEID #: 24
U.S. DEPARTMENT OF THE TREASURY

BUREAU OF THE FISCAL SERV]CE

WASHINGTON,D.C.2O2z7

ACTING ON BEHALF OF

U.S. Department of Labor, Occupational Safety & Health Administration

CERTIFICATE OF TNDEBTEDNESS

Kare Medical Transport

c/o Jason Keeran

1000 Columbus Ave.

Marysville, OH 43040

RE: Treasury Claim TRFM2015034440

I certiry that the U.S. Department ofLabor, Occupational Safety & Health Administration (OSIIA)

records show that the debtor named above is indebted to the United States in the amount stated as

follows:

Principal:

Interest through 06/21/ 18+ :

Penalty fee through 06/21/18*:

Admin fee:

DMS fees:

DOJ fees:

$32,670.00

$ 1,267.86

$ 7,443.84 $ 20.00

913,248.s4

$ 1,690.21

(pusuant to 3l U.S.C. 3?17(e) and 371l(9)(6), (7); 3l C.F.R. 285.12(i) and 31 C.F.R. 901.1(0; and 28 U.S.C. 527, note)

TOTAL debt owed as of06/21118: 556,340.45

*NOTE: Per the creditor agency, once the debt is referred to Fiscal Service, interest continues to accrue at

the rate of l% per annum as well as a penalty at the rate of 6010 per annum.

This debt reponedly arose in connection with the numerous workplace safety violations ofthe

Occupational Safety and Health Act of 1970 (29 U.S.C. 650/651 et seq.) aad OSIIA regulations (29

C.F.R. 1926), as noted during the original December 2013 OSHA inspections as well as the June 2014

follow-up inspections ofthe debtor's work site at 1000 Columbus Ave, Marysville, OH 43040.

CERTIFICATION: Pursuant to 28 USC ss. 1746, I certiff under penalty ofperjury that the foregoing

is true and correct to the best of my knowledge and beliefbased upon information provided by the U.S.

Department ofLabor, Occupational Safety & Health Administration.

x ?lJe+ t&*--s--

Ashleigh Edmonds

Financial Program Specialist

U.S. Department of the Treasury

OOVERNMENT

EXHIBIT

tr

s

i

3

E

Bureau ofthe Fiscal Service

Debtor Name(s) and Address(es):

sisn.d t). Ashleigh N. Edlrcnds

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-6 Filed: 08/22/18 Page: 1 of 1 PAGEID #: 25
\,S:rl (ReY r2l07) cIvL covER SHEET

IhC CIV'I OOCIEI ShCEt (SET INSTRUC'TIONS ON IHE RIVIRSE O} THL IORM I

L (a) PLAINTIT'FS

UNITED STATES OF AMERICA

(b) Countl ofxesdence ofFirst I.isted I,la,ntifi'

DEFENI}ANTS

KARE MEDICAL TRANSPORT

County ofResidenc€ ofFirst Listed Defendant UNION

ONU,S, PLAINTIFF CASES ONLY)

NOTE: lN LAND CONDEMNATION CASES. USE THE LOCATION Or THE

LAND INVOLIIED

(C) Anomev srl'mNm. AddFss md r.l.Dhon. N,mh.'r

BETHANY J. HAMILTON, Assistant United States Attorney

303 Marconi Boulevard, Suite 200, Columbus, Ohio 432'15

Attomeys (lf (nown)

Cirim or Subject of a O3 O I tor.ig, Nstion

I U S Covffi.nt

Plaindff

C, 3 F.d.rsl QBrion

(U.S. Covcrtrnor Not a PaV)

O 4 Divftity

(Indiclt! Citiaship of P.nics in lt.m lll)

Cinzm ofAnolher Stlt J2 A 2 Incorpomr.d azrktucipat Plee

of Aunn.s In Anorhn Slarc

o 5 tl5

o 6 d6

CO\TR{C I' FORFEITURX/PT\ALTY B\\Iikl I'r ( \ o I tluR

O 422 App6l2E USC l5E

O 423 Withdmwal

28 USC t57

PROPtiRTI Rt(,lltS

O 610 A8ric'rr@

O 620 othcr Food & Dog

O 625 Drug Rclrtcd S.iz@

of Plopcrty 2 I USC EE I

O 630 Liquor Laws

O 640 R.R. & Truct

O 650 Airlinc Rcgs.

O 660 Oeupatio!.I

Stfdy/Halh

O 690 O!t!.r

O 620 Coprrishts

O E40 TEdmark

s()ctaL sa('tri TI

J

o

o

o

D

o

a

o

o

Pf,RSONAL INJTJRY

315 Arpld. Producr

Liability

320 Asauh, Lib.l&

Sledd

330 F€d.ral Eoploy.6

Liability

Liability

Injry

o 86tHIA(1395tr)

O 862 BlackLos(923)

O 861 DIwC,DIww (405(g))

o 864 SSID Tirlc XVI

O 865 RSI (405(r))

RTAL PROPERTT' al\'lI RI(:ln s PRISo\[R PI:-I'ITIO\S Tf,DER{LTA\ ST ITS

tl 7 | 0 Fair Lsbor Sl.n&rds

O 720 L.bo./Mgnt R€lations

O 730 LaborMgDtRcponirg

& Di*losE Act

O ?40 R.ilwly Labor Act

O 790 olh.r Lsbor LitiSltron

O 791 EEpl. R.t. Lc.

I Nrll lG R{Tlo}r

O ,t4l Votin8

O 442 Employmdt

O a4l HoBing/

Accomodltions

O 444 wclfe

O 445 tutrq. w/Diebiliti.s -

O 446 Am6. */Disrbiliti.s -

Od'cr

o 440 Orhdci l tuShls

O 5 | 0 Motiolrs to Ya..t

O 530 Cq.nl

d 535 D.6th P.oalty

D J40 MsrdmB & Otr'er O 550Ciyiltudts

O 5J5 kison Cotdilion

O 462 N.tuBIiztion Applicadon

3 463 Hrh.s CorB6 -

O 165 olh.r Imigration

O E70Ta6(U.S. Plai ifr

O 871IRS Thiid Pany

26 USC 7609

r

IV. NATURE OF ST]IT PI

O Il0lnsljl2e

O I20 Mdift

O I l0 Mill6 Act

D 140 Negoriable Inslrummr

O 150 Recovery of Ov.rpaymcnr

& Enf()lldmr ofJrdgn.

O lJl M.dice Aci

d 152 R@vcry of Dcfluh.d

O 400 5l.l. R.arDonionm€lt

O 4l0AntitusI

O 430 Bdks od Aanhng

O 450 Conmcrce

O 460 D.porlation

O 470 Rackcl.d InflMed dd

Compl OrSaniaio6

O 4EO Consum.r Crcdit

O 490 Csbla,Sit Tv

O El0 S.l..rivc S6vic.

O 850 Sccuiti.rcomoditieY

B 8?5 Custom.r Chall.Dg!

l2 usc 34 r0

O 8m Olhd Slatutory Actios

O 891 ASriculnral Acts

O E92 Economic Slabiliatim Act

O E93 Enltom.ntal M6tl6

O 894 En.r$/ All@ati6 Acr

O E95 Frccdom of Infotuation

O 900App.a1 of Fce Del.minetion

Undc. Equal Access

O 950 Cmsitutimality of

(Ercl.va.la)

O 153 R@overy ofovcrpaymcnt

of V.r€m'sBn.fits

O 160 SiocHoldeB' Suits

El I90 orh6 Conllcr

O 195 Cont!&t Prodoct Liabiliry

t l% tmchi$

O 210 trd CqxLll@tid

O 220 Forcd()s@

O 230 R.nt L.4 & Ejetmcnt

O 240 Torts to Ls.d

O 245 ToIt Prcd@t Liability

O 290 AI Odrr R.al Prop.rty

V. ORIGIN

E I Orisinal

Proceeding

(Plac. d "x'i! Otr. Box Only)

O 2 Removed liom O 3 Remanded from

Slate Court Appellate Coun

Appeal lo Distflct

D 4 Reinstated or O Judge from 5

Reopened

06 Multidistsict O 7

LitiBation

Cite the U S Civil Statute under rvhich you are filing (Do not cit. jurisdiction.l st.tul.s utrl.ss div.rsity)

Brief description of cause

VII. REQUESTED IN

COMPLAINT:

O CHECK IF THIS Is A CLA.S ACiIoN

UNDER F,R.C P 23

DI.]NIAND S

M

VI. CAUSE OF ACTION

CHECK YES only ifdemanded in complaint

JURY DEMAND: C, Yes O No

FOR OFTICf, USE

RECEIPT C A]\{OUNT

EYO

MAG JUDGE

I)OCKIT NT]MI}I:R

DAl E

I

U.S. Attorney

NAI'

(EXCET'I IN U,S, PLAINTIFF CASES)

Il. BASIS OF JTJRISDICTION (r)rrr.nn x"in(hcBo\(r,h)

n 2 IiS G.vemmeni

III. CITIZENSHIP OF PRINCIPAL PARTIEs(phce a" -x" iD one Box ror prainriff

(Fo. Dive6iryCas6 only) ed On. Box for Dcf.nd4o

PTT Df,T r T DTF

Citizo ofThis Slale O I O I lncorpoBtcd or ftincipsl Plac. O 4 34

ofB6iD6s ln This Stat

PERSONAL INJURY

O 362 P@.al Iniury -

M.d. Mdpnctie

O 365 Pd$nal Injury -

hud Liability

O 368 Asb.stos Pcmnd

InjEy ProdEt

Liability

PERSONAL PROPf,RTY

O 370 Othcr F6ud

O 371 Truth in Lcnding

n 180 Olh.r P.Mn,l

Prcp.ny Darnse

O 3E5 Propcny Dahag.

ProdEt Liability

APPLYINC IFP JUDGE

vlll. RELATED CASE(S)

IF ANY

Case: 2:18-cv-00933-EAS-KAJ Doc #: 1-7 Filed: 08/22/18 Page: 1 of 1 PAGEID #: 26