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HomeMy WebLinkAboutExemption RequestFLORIDA DEPARTMENT OF STATE s Florida law allows certain persons to request that an agency not publicly disclose specific identification and:or location inforntalion contained in any of its agency records. Please refer to sections 119.071(2)(I ). (4)(d). and (5)(i). 265.605, and 267.17, Fla Stat., or other applicable statute for scope of protection which may include home address, phone numbers, photos. name of spouse and/or children, anti their place of employment, and/or school or daycare care facility, and date of birth. To request the exemption for information contained within records of the Department of State, please complete the form and return to: Secretary of State. c/o Public Records Custodian Director, R.A. Gray Building, 500 S. Bronough St., Tallahassee, FL 32399. For more information, contact 850-245-6536. To request the claim for exemption extend to your spouse and for children (not applicable for victim' exemption) please submit a separate sheet with the name, date of birth, and relationship for purposes of identifying them in any public records within the custody of the Department. (If you have attached supplemental pages check here❑ ) If you have any records with the Division of Corporations that include exempt information please check here ❑ and complete the Addendum for Exemption of Public Disclosure. Otherwise, there is no need to complete the .Addendum for Exemption of Public Disclosure. You will only be contacted if the information you provide is insufficient to identify you distinctly from someone else similarly named in the records or if die information provided is insufficient to demonstrate the applicability of a public records exemption. I attest that I am ant individual covered under Section 119.071, F.S., as, check the appropriate item (only one): 15, current or ❑ boner ❑ spouse of a current or spouse of a former child of a current or child of a former and I hereby request the exemption (check applicable exemption category): ❑Addiction treatment facility, licensed pursuant to Chapter 397, F.S.. directors. managers, supervisors. nurses, and clinical employees Is. 119.071(4)(d)2.$) Child advucacv center, meeting the standards set forth in Chapter ❑ 39. F.S., directors• managers, supervisors. and clinical employees and membersot'a Child Protection Team a, set forth io s. 39.303, ES. (s. 119.071141(d)2.0 ❑ Code Enforcement Officer (s. 119.071(4)((l 121) ❑ County Tax Collectors. 119.071(4)(d)2.n) Dept. of Agriculture and Consumer Services inspectors and ❑ mvestigators(s. 119.071(41(d)2.c.) ❑Dept. of Business and Professional Regulation -investigators and inspectors is. 119.0'11(4)(d)2.m) Dept, of Children and Family Services personnel whose duties involve investigation of abuse. neglect. exploitation, food. theft. or other criminal activities (s. 119.07)14)(d)2_a) Dept. of Financial Services investigative personnel whose duties include the investigation of fraud, the0. workers' compensation coverage requirements and compliance. other related crinutnal activities, or state regulatory requirement violations is. 119.07I(4)(d)2.b) Dept. of Health personnel whose duties support the investigations ❑ of child abuse or neglect, determination of benefits. or the mvestrgatiou, inspection, or prosecution of health care practitioners is.. 119.071(4)(d)2.u) Dept. of Health personnel whose duties include. or result in. the ddlemriratinn, or adjudication of eligibility for social security ❑ disability benefits. the investigation orpmsecution ofiximpkints filed against health care practitioners, or the inspection of health care practitioners or health nut facilities licensed by the Department of1-leallh is. 119.071(4)(d)2.0) Dept. of Revenue personnel or local govcmment personnel whose duties relate to revenue collection anti enfoneumnt or child uppnn enticement. is. 119.07104,11^ a) ❑Domestic violence genes. certified under Chapter 39. F.S.• staff and domestic violence nth uc:0es as defined in s. 90.5036(1)(b). F.S. is. 119.071(4)(d)2a0 Emergency medical technicians or paramedics certified under ❑ Chapter 401. F.S is. 119.07114)(d)2.q) ❑firefighter certified in compliance with s. 633.4os. r5. is. 119.071(4)(d)3.d) ❑ Otoudian ad litem(s. 119.0710)(d)2d) Human resource. labor relations, or employee relations director. ❑ v1,istant director, manager or assistant manager of any local vn emnam agency or water manageutett district (s. 'I 19.071(4)(d)2L) Impaired practitioner consultants whose duties result in a ❑ detenninatinn of it prison's skull and satiety to practice a licensed profession Is. 119.071 (4 )(d )2.p ) Inspector general employees or internal audit department employees Elwhose duties include auditing or investigating waste, fraud. abuse. Iheil. exploitation. or other activities that could lead to erindnal prosecution or administrative discipline is. 119.0710)(d)2.0 ElJudge - district court of appeal. circuit coun :rod county court. or justice of the Florida Supreme Court is. I I9.071(4)(d 12 e ) ❑('uman judicial assistant (court employee assigned to the fidlowing doss codes: 8140.. 8150. 8310. and 8320) is. 119.071(4)(d12.r) ludici:d or quasi-judicial officer (general and special magi.traw, ❑judge of compensation claims. administrative law judge of the Division of Administrative Hwrings, and child support embrecinent hearing officer) is. 119.07114)fdl2.9l uvenile probation officer, juvenile probation supervisor, detenion superintendent. assistant detention superintendent. ❑senior juvenile detention officer. juvenile detention officer s'upervusnr. juvenile detention officer, house parent I and B, house parent super ivu', group treatment leader, group treatment leader supervisor. rehabihtmiun dcergri>I. ;mJ social services counsukn ofthe Dept. of Juvenile Justice (a. 119.071(4)(d)21) ❑Law erihn'ceuent personnel including correctional officers and correctional probation officers (s. 119.071 t41td)2.:r) Olfit" of Financial Regulation, Bureau of Financial ❑ Imestig>nurrts, invesugaocc personnel whose duties include the investigation of fraud, then. other related criminal activities or ,state regulatory requirement cioknioro (s. 119.071(4)Id 12.c ) ElProsecutor lactate anomey, assistant state :Honig'. statewide prosecutor, aysiffiant statewide prosecutor) fs. 119.071(4)Itl)2.1) Public dOmders. and criminal coulwi and civil regional counsel ❑ (Includes assistant public delenders, assistant n'inunal conflict and assistunt civil regwual counsel) (s. 119.071(4)(d)? II I.S. atnnnev or assistant attorney. U.S. appellate judge. U.S district court judge and U.S. magtsuute (By signature below, person certifies that reasonable efforts made m protect infomration from being publicly accessible by other means) (S. 119.071(5 )(it Current county attorney, assistant county attorney, deputy county attorney, city attorney. assistant city attorney, fir deputy city anomey (s. 119.071(4)(d)2,w) ❑ Current clerk ofcircuit coup, deputy clerk of circuit court. or clerk of circuit court personnel (a. 119.071 f4)(d)2 yI Person employed by the United States Depzrtnrem of Defense who is authorized lu access information that is deemed "secret" or "top secret' by the Federal Government or who is a servicemanber urn special operations force (s. 119.071(5)(k)) Victim" of sexual bauerv, aggmvated child abuse, aggravated stalking, harassment. aggravated battery or domestic violence. "Must attach official verification that crime occurred." Is. 119A71(2)(I)) 5- year exemption. Commissioner of the Florida tuning Control C'ouunission (Contact Attorney General's Office (850414-3300) about eligibility Is. 1191171(4)(d)2.x) fist separate Address Confidentiality Program. See s. 741.465. Fla. Steil Current Coneressiored Member OR Public Officer. Please submit the inlinmation rcyuaad by s. 119.071(4)(d)3.6. which Other (must list applicable statute may be cong>leled sin are attached page 4. (s. 119.07l(4)(d)2.z.) C% // 1' �q Printed Name: Nut Date Date of Birth I )-- / 517g1one Number: (772) 633-7597 Home Address: 709 Jc t3i3n Avein, aim, FL 3295E Signature: � — Date: to Section l 19.071(4)(d)3.. F.S., your request must be notarized. The requestor hereby swears or affirms, under penalty of Grit, . that the information contained in the foregoing public record exemption form is true and correct. REOUIRED NOTARIZATION SECTION STATE OF FLORIDA COUNTY OF kdim 1River The foregoing Public Records Exemption Request was sworn to (or affirmed) and subscribed before me by means of Ekphysical presence or ❑ online notarization, this 191-h day of A nst , 1025 , by Cltdsb#Er Nan , who is: X personally known to me OR produced the following identification: "�(f E WIL(•,, Si ature of Notary Public - State of Florida s VPI� a,202 7 Jeffisthe W i Licm oQ Print, Type, or Stamp Colnmissioned Name of Notary Public ADDENDUM FOR EXEMPTION OF PUBLIC DISCLOSURE ONLY FOR DIVISION OF CORPORATIONS RECORDS Before the Florida Department of State, Division of Corporations can act on your request it needs the following additional information from you: 1. Complete home address to be redacted: 2. Are you now or have you ever been listed on the Division of Corporations' records as a Registered Agent? ❑ Yes ❑ No If you answered "Yes" to this question and the address to be redacted is the Registered Agent address, you must provide an alternate Florida Street Address that can replace the one we currentiv have in our records. 3. Is your home address the principal place of business address for a corporation, limited liability company, or limited partnership, for which you wish to have redacted? ❑ Yes ❑ No If you answered "Yes" to this question and the address to be redacted is the principal place of business address for a corporation, limited liabilitv comuanv. or limited uartnershim you must provide an alternate Street Address that can replace the one we currently have in our records. 4. Are you now or have you ever been listed on the Division of Corporations records as: a. An officer or director of a corporation? ❑ Yes ❑ No b. A managing member or manager of a limited liability company? ❑ Yes ❑ No c. A general partner in a limited partnership? ❑ Yes ❑ No d. An owner of a fictitious name? ❑ Yes ❑ No e. A partner in a general partnership? ❑ Yes ❑ No f. A notary? ❑ Yes ❑ No g. An owner of a trademark registration? ❑ Yes ❑ No If you answered "Yes" to one or more of the above questions, you must provide an alternative address to replace the one we currently have in our records. This address may be a P.O. Box; however, if the address being replaced is for a Registered Agent or a principal place of business, please see numbers 2 or 3 above or call the Division of Corporations at 850-245-6999 for further information. 5. Have you ever had a judgment lien filed against you that would have been filed in this office after October 1, 2001? ❑ Yes ❑ No Name/Names of entity, registration, or notary. Please provide corporate document number or, if applicable, your Notary ID number, if kno%vn: Alternate address to replace the one current on our records. See requirements listed above. Page 4 REQUIRED INFORMATION FOR EXEMPTION OF INFORMATION FOR CONGRESSIONAL MEMBERS OR PUBLIC OFFICERS PURSUANT TO SECTION 119.071(4)(d)3.h., FLORIDA STATUTES Please Note: This page is not required unless your exemption is as a Congressional Member or Public Officer as set forth in Section 119.071(4)(d)2.z., Florida Statutes. The following information is required by the Florida Legislature to be included in a request by a Congressional Member or Public Officer (as defined in Section 119.071) submitted to a non -employing agency requesting that agency to maintain specified information exempt from public records disclosure: (1) The date of the Congressional Member or Public Officer's election or appointment to public office: NNetber 7, 2023 (2) The date on which that office is next subject to election: . - .� ..ir And, if applicable: (3) The date on which the current Congressional Member's or Public Officer's minor child reaches the age of majority: