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HomeMy WebLinkAboutRequest for ExemptionCITY OF SEBASTIAN RECEIVED Public Records Exemption Request APR 19 2023 Florida law provides that an agency shall treat social security numbers, bank account numbers, and debit, charge, and credit card numbers as automatically exempt from public disclosure. In addition, Florida law allows eligible persons to submit a written and notarized request at a non -employing agency maintain as exemptfrom public disclosure certain identification and/or location information contained in records within the a OftG*bastian The person entitled to the additional exemptions must submit a written and notarized request directly to this agency to QMyaiEl6g'Wrgy01ffl * the records in our custody. 4 119.071(4)(d)3., F.S. You are not required to use this form; however doing so will help us keep your information confidential. Please return this completed form or a written and notarized request to: City of Sebastian, 1225 Main Street, Sebastian, FL 32958 If you or your spouse qualify; or if you are the child of someone who qualifies; you are eligible to receive additional public records exemptions. Please check the box for any of the following that apply: Acti or Former: Sworn or civilian law enforcement personnel, including correctional and correctional probation officers. ❑ Department of Children and Families personnel whose duties include investigating criminal activities. ❑ Department of Health personnel whose duties are to support the investigation of child abuse or neglect. ❑ Department of Revenue or local government personnel whose responsibilities Include revenue collection and enforcement or child support enforcement. Current or Active: ❑ General magistrate, special magistrate, judge of compensation claims, administrative law judge of the Division of Administrative Hearings, or child support enforcement hearing officer. ❑ County Tax Collector. ❑ Child protection team members. Current or Former: ❑ Department of Financial Services nonsworn investigative personnel whose duties include investigating criminal activities, workers' compensation coverage requirements and compliance, or state regulatory requirement violations. ❑ Supreme Court Justice, or judge of district court of appeal, circuit court, or county court. ❑ State attorney, assistant state attorney, statewide prosecutor, or assistant statewide prosecutor. ❑ Public defender, assistant public defender, criminal conflict and civil regional counsel, and assistant criminal conflict and civil regional counsel. ❑ Human resource, labor relations, or employee relations director, assistant director, manager, or assistant manager of any local government agency or water management district whose duties include hiring/firing employees, labor contract negotiation, administration, or other personnel -related duties. ❑ Code Enforcement Officer. ❑ Guardian ad litem, as defined in s. 39.820, F.S. ❑ Guardian ad litem, as defined in s. 39,820, F.S. Juvenile probation officer, juvenile probation supervisor, detention superintendent, assistant detention superintendent, juvenile justice detention officers I and 11, juvenile justice detention officer supare' or, juvenile justice residential officer,juvenile justice VYes, I qualify ❑ Yes, my spouse q Printed Name: re to The residence address(es) you wish us to maintain as confidential OATH I, the person Whose name appears at too begmrwtg of this form, m depose on oath or affirmation and say that the information c1mclosed on thts form and any arlbahnh iu, naretd rs true, a=rat a, and complete. SIGNATURE OF REPORTING OFFICIAL OR CANDIDATE residential officer supervisors I and II, juvenile justice counselor, juvenile justice counselor supervisor, human services counselor administrator, senior human services counselor administrator, rehabilitation therapist, or social services counselor of the Department of Juvenile Justice. ❑ Department of Business and Professional Regulation investigator or inspector. ❑ Department of Health personnel involved in determining or adjudicating eligibility for social security disability benefits, investigating or prosecuting complaints filed against health care practitioners, or inspecting health care practitioners or health care facilities licensed by the Department of Health. ❑ Impaired practitioner consultant retained by an agency, or employees of such a consultant. ❑ Certified emergency medical technician or paramedic. ❑ Personnel employed in an agency's office of inspector general or internal audit department whose duties include auditing or investigating activities that could lead to criminal prosecution or administrative discipline. ❑ U.S. Attorney or Assistant U.S. Attorney, U.S. Courts of Appeal judge, U.S. district judge, or U.S. magistrate.* ❑ Victim of sexual battery, aggravated child abuse, aggravated stalking, harassment, aggravated battery, or domestic violence (if applicable, must attach official verification that crime occurred; exemption applies only to individual victim of specified crime, not to the spouse or child of thevictim).** ❑ Certified firefighter. ❑ Nonsworn investigative personnel of the Office of Financial Regulation whose duties include investigating fraud, theft, criminal activities related to fraud or theft, and violations of state regulatory requirements. ❑ Child Advocacy Center Directors, managers, supervisors; and clinical employees. ❑ County addiction treatment facility directors, managers, supervisors, nurses, and clinical employees. ❑ Public guardians, and those employees of public guardians with fiduciary responsibilities. ❑ Staff and domestic violence advocates of domestic violence centers certified by the Department of Children and Families under Chapter 39, F.S. ualifies ❑ Yes, my parent qualifie Phone Number: r-21,A)YIS— � �97 1— STATE OF FLORIDA_ COUNTY OF rbid : SW in to to (or afirtbed) and subsenbed berate nby meah9pf (Vphysidal presence or 0 online notanrz�atlon, Dim _�Q-,,,.,___„ day of ._. _ j . 20 Z,/ Qby r _t-2GQFX1 Glt�.r J. O.P12.$. f5igna n of Nntary Publie.•Staio of FA:roa) Wsts K T n mall 1.1: 1/ +:ems (Yrint. ryPe, Or a -lamp e:dmmesstnded Name nt M01IRy YapVCI r ..* _Nr" Personally Known OR PrdduGed idooefication MY Type of IdentAvatron Produced CO n a'f *- If this category is selected, person also certifies, by signing this form, that he or has made reasonable efforts to Ihepublic. --exemption validfor 5 years from dote of request.