Florida law allows certain persons to request that an agency not publicly disclose specific identification and/or location information contained in any of its agency records. Please refer to sections 119.071 (2)(j), (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, and their place of employment, and/or school or daycare care facility, date of birth. A separate request must be submitted for each protected individual (including spouses and children).
To request the exemption for records in our agency, please complete the form and return to: ______
I hereby certify that I qualify for exemption from the Public Records Law and request that all allowable information be maintained as confidential. I am:
The person covered by the category below.
The spouse of the person covered by the category below.
The child of the person covered by the category below.
and I am requesting exemption under the following category:
Current or former code enforcement officer.
County Tax Collector †
Current or former Dept. of Business and Professional Regulation-investigators and inspectors†
Dept. of Children and Family Services personnel whose duties include investigation of abuse, neglect, exploitation, fraud, theft, or other criminal activities
Dept. of Health personnel whose duties support the investigations of child abuse or neglect
Current or former Dept. of Health personnel whose duties include, or result in, the determination or adjudication of eligibility for social security disability benefits, the investigation or prosecution of complaints filed against health care practitioners, or the inspection of health care practitioners or health care facilities licensed by the Department of Health †
Dept. of Revenue personnel or local government personnel whose responsibilities include revenue collection and enforcement or child support enforcement
Donor or prospective donor,* Cultural Endowment
Program Trust Fund, Citizen Support Organizations or National, Historic Landmarks (publicly owned houses)
Firefighter certified in compliance with s. 633.408, F.S.
Current or former 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 and firing employees, labor contract negotiation, administration, or other personnel-related duties
Current or former justices of the Supreme Court, district court of appeal judges, circuit court judges, and county court judges.
General and special magistrate, judge of compensation claims, administrative law judge of the Division of Administrative Hearings, and child support enforcement hearing officer †
Current or former juvenile probation officer, juvenile probation supervisor, detention superintendent, assistant detention superintendent, juvenile justice detention officers I and II, juvenile justice detention officer supervisor, juvenile justice residential officers, juvenile justice residential officer supervisors I and II, juvenile justice counselors, juvenile justice counselor supervisors, human services counselor administrators, senior human services counselor administrators, rehabilitation therapists, and social services counselors pf the Dept. of Juvenile Justice
Active or former sworn or civilian law enforcement personnel including correctional, officers and correctional probation officers
Current or former state attorney, assistant state attorney, statewide prosecutor, assistant statewide prosecutor
Current or former public defenders, assistant public defenders, and criminal conflict and civil regional counsel, and assistant criminal conflict and civil regional counsel
Current or former U.S. attorney or assistant U.S. attorney, U.S. appellate judge, U.S. district court judge and U.S. magistrate †
Victim* of sexual battery, aggravated child abuse, aggravated stalking, harassment, aggravated battery or domestic violence
Current or former guardian ad litem†
Current or former member of the Armed Forces of the United States, a reserve component of the Armed Forces of the United States, or the National Guard, who served after September 11, 2001†
Other (list applicable statute): ______
Printed Name:______Date of Birth:______Phone Number:______
Home Address: ______
Signature: ______Date: ______
†For category selected, I certify, by signature herein, that I have made reasonable efforts to protect information from being publicly accessible.
*Spouse and/or child exemption not available for these categories.