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Home My WebLink AboutRequest for Exemption ITY OF SEBASTIAN Public Records Exemption Request 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 that a non -employing agency maintain as exempt from public disclosure certain Identification and/or location information contained in records within the agency's custody. The person entitled to the additional exemptions must submit a written and notarized request directly to this agency to maintain the exemption to the records in our custody. 5 119.071(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: Act' a or Former: Sworn or civilian law enforcement personnel, including correctional and correctional probation officers. D 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. D 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 lawjudge of the Division of Administrative Hearings, or child support enforcement hearing officer. ❑ County Tax Collector. ❑ Child protection team members. Current or Former: D Department of Financial Services nonsworn investigative personnel whose duties include investigating criminal activities, workers' compensation coverage requirements and compliance, or state regulatory requirement violations. D Supreme Court Justice, or judge of district court of appeal, circuit court, or county court. D State attorney, assistant state attorney, statewide prosecutor, or assistant statewide prosecutor. D 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 (item, 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 supervisor, juvenile justice residential officer,juvenile justice 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.5. 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 the victim).`• ❑ 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. �( Yes, I qualify ^❑i nYe�ss,,,my spouse qualifies El Yes, my parent qualifies Printed Name: S%1cXYl I tip I h ews Phone Number: / --"l2� 7 3- (0`75-4- The residence address(es) you wish us to maintain as confidential �LZ7 \�eGJ Y l 5e-ba si7a J AFL, OATH I. the person %hose name appears at tha begmmng of this form, do depose on oath or affirmation and say that the information d,sclosed on this form and any attachments hereto is true, accurate. and complete. SIGNATURE OF REPORTING OFFICIAL OR CANDIDATE STATE OF FLORIDA� COUNTY OF Swum to (or affirmed) and subscnbod before me by m p! physical presence or I] ornme notarisation, Nis my of -.2o23 by �(nerrie. iAa}rHtws (Signature of ry PubNc--State of Fbndal �iTe �.'•.�....... (Pr;nt, type, or StampjCa/mmiu ss;oned Name off Notary PuW,CI a :aD Persona4v Known ✓ OR Produced idenbfrcaboG Tyre of Identification Produced •-Ifthis categoryis selected, person also certih'es, by signing this form, that he or she has made reasonable efforts to protect such Information from being accessibt µsvt ther means the Public. Z '� "—Exemption valid for 5 years from date of request. /n .q �OF A