florida department of state - public records exemption request(rev

LORIDA DEPARTMENT OF STATE

PUBLIC RECORDS EXEMPTION REQUEST

(REV. 08/2021)

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, 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/or children (not applicable for donor* or victim* exemptions) 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 )

In order to process this request for any of your records that may be in the Division of Corporations, please complete the Addendum for Exemption of

Public Disclosure. If you do not have any records with the Division of Corporations that include exempt information please check here .

You will be contacted if the information you provide is insufficient to identify you distinctly from someone else similarly named in the records or if

the information provided is insufficient to demonstrate the applicability of a public records exemption.

I attest that I am an individual covered under Section 119.071, F.S., as, check the appropriate item (only one):

current or former

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 (s. 119.071(4)(d)2.s)

Child advocacy center, meeting the standards set forth in Chapter

39, F.S., directors, managers, supervisors, and clinical employees

and members of a Child Protection Team as set forth in s. 39.303,

F.S. (s. 119.071(4)(d)2.t)

Code Enforcement Officer (s. 119.071(4)(d)2.i)

County Tax Collector (s. 119.071(4)

(d)2.

Dept. of Business and Professional Regulation-investigators and

inspectors (s. 119.071(4)(d)2.m)

Dept. of Children and Family Services personnel whose duties

involve investigation of abuse, neglect, exploitation, fraud, theft,

or other criminal activities (s. 119.071(4)(d)2.a)

Dept. of Financial Services investigative personnel whose duties

include the investigation of fraud, theft, workers’ compensation

coverage requirements and compliance, other related criminal

activities, or state regulatory requirement violations

(s. 119.071(4)(d)2.b)

Dept. of Health personnel whose duties support the investigations

of child abuse or neglect, determination of benefits, or the

investigation, inspection, or prosecution of health care practitioners

(s. 119.071(4)(d)2.a)

Dep

t. 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 (s. 119.071(4)

(d)2.

Dept. of Revenue personnel or local government personnel whose

duties relate to revenue collection and enforcement or child support

enforcement. (s. 119.071(4)

(d)2.

Domestic violence centers, certified under Chapter 39, F.S., staff and

domestic violence advocates as defined in s. 90.5036(1)(b), F.S. (s.

119.071(4)

(d)2.

Donor or prospective donor,* Cultural Endowment Program Trust

Fund, Citizen Support Organizations or National, Historic Landmarks

(publicly owned houses) (sections 265.605 and/or 267.17)

Emergency medical technicians or paramedics certified under Chapter

401, F.S (s. 119.071(4)

(d)2.

Firefighter certified in compliance with s. 633.408, F.S.

(s. 119.071(4)

(d)2.

Guardian ad litem (s. 119.071(4)

(d)2.

Human resource, labor relations, or employee relations director,

assistant director, manager or assistant manager of any local

government agency or water management district

(s. 119.071(4)

(d)2.

Impaired practitioner consultants whose duties result in a

determination of a person’s skill and safety to practice a licensed

profession (s. 119.071(4)

(d)2.

Inspector general employees or internal audit department employees

whose duties include auditing or investigating waste, fraud, abuse,

theft, exploitation, or other activities that could lead to criminal

prosecution or administrative discipline (s. 119.071(4)

(d)2.

Judge - district court of appeal, circuit court and county court, or

justice of the Florida Supreme Court (s. 119.071(4)

(d)2.

Judicial or quasi-judicial officer (general and special magistrate,

judge of compensation claims, administrative law judge of the

Division of Administrative Hearings, and child support

enforcement hearing officer) (s. 119.071(4)

(d)2.

Juvenile probation officer, juvenile probation supervisor,

detention superintendent, assistant detention superintendent,

senior juvenile detention officer, juvenile detention officer

supervisor, juvenile detention officer, house parent I and II, house

parent supervisor, group treatment leader, group treatment leader

supervisor, rehabilitation therapist, and social services counselor

of the Dept. of Juvenile Justice (s. 119.071(4)

(d)2.

Law enforcement personnel including correctional officers and

correctional probation officers (s. 119.071(4)

(d)2.

Office of Financial Regulation, Bureau of Financial

Investigations, investigative personnel whose duties include the

investigation of fraud, theft, other related criminal activities, or

state regulatory requirement violations (s. 119.071(4)(d)2.c.)

Prosecutor (state attorney, assistant state attorney, statewide

prosecutor, assistant statewide prosecutor) (s. 119.071(4)(

d)2.

Public defenders and criminal conflict and civil regional counsel

(includes assistant public defenders, assistant criminal conflict and

assistant civil regional counsel) (s. 119.071(4)

(d)2.

U.S. attorney or assistant attorney, U.S. appellate judge, U.S district

court judge and U.S. magistrate (By signature below, person certifies

that reasonable efforts made to protect information from being

publicly accessible by other means) (S. 119.071(5)(i)

Victim* of sexual battery, aggravated child abuse,

aggravated

stalking, harassment, aggravated battery or domestic violence [Attach

official verification that crime occurred. 5-year exemption. Contact

Attorney General’s Office (850-414-3990) about eligibility for

separate Address Confidentiality Program. See s. 741.465, Fla. Stat]

Other (list applicable statute):

Printed Name: __________________________________ Date of Birth: _____________ Phone Number: __________________________

Home Address: __________________________________________________________________________________________________

Signature: ______________________________________________________________ Date: ___________________________________

Pursuant to Section 119.071(4)(d)3., F.S., your request must be notarized. The requestor hereby swears or affirms, under penalty of

perjury, that the information contained in the foregoing public record exemption form is true and correct.

REQUIRED NOTARIZATION SECTION

STATE OF FLORIDA

COUNTY OF ____________

The foregoing Public Records Exemption Request was sworn to (or affirmed) and subscribed before me by means of

☐ physical presence or ☐ online notarization, this ___________ day of _____________________ , 20________ , by

________________________________________________, who is:

________ personally known to me OR

________ produced the following identification: ___________________________________________

____________________________________________

Signature of Notary Public - State of Florida

____________________________________________

Print, Type, or Stamp Commissioned 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 that is to be redacted:

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

3. Have you ever had a judgment lien filed against you that would have been filed in this office

after October 1, 2001 Yes No

If you answered “Yes” to one or more of the questions, and the address to be redacted is the Registered

Agent address you will need to provide the name of the entity, registration or filing and an alternate

Florida street address that can replace the one we currently have in our records. We cannot have a

record with a missing Registered Agent address.

If the address to be redacted is the principal place of business address for a corporation, limited

liability company, or limited partnership you will need to provide the name of the entity, registration

or filing and an alternate street address that can replace the one we currently have in our records.

We cannot have a record with a missing principal place of business for these entities.

Name/Names of entity or registration:

Alternate address to replace the one current on our records. Must be a Florida street address for replacing

a redacted registered agent address. Must be a street address for replacing a redacted principal place of

business for a corporate entity:

Please return this addendum with the Public Records Exemption Request form.

For questions concerning this addendum, call 850-245-6536.

Office of Nikki Alvarez-Sowles, Esq.

Pasco County Clerk & Comptroller

OFFICIAL RECORDS DIVISION

REQUEST FOR REDACTION OF INFORMATION PURSUANT TO F.S. 119.071

– PROTECTED STATUS

Pursuant to F.S. §119.0714(3)(f), in order for a person who is authorized under F.S. §119.071(4)(d)2 to request an exemption from official records, the

requestor must submit a request to the office of the Clerk & Comptroller, and specify the document type, name, identification number, and page number of

the official record that contains the exempt information.

Current/former/government agency employee in the category indicated below.

Spouse of a current/former government agency employee in the category indicated below.

Child of a current/former government agency employee in the category indicated below.

I __________, proclaim that I am entitled

(Requestor)

to protection of the confidential information listed under this statute due to my service as noted

in F.S. 119.071(4)(d)2__________________________________________________________

Address & Telephone Number: ________

SSN Date of Birth Name/Location of School/Daycare Facility of Child Photo

Place(s) of Employment/Location

Include the following name(s) of my child(ren) if under 18 YOA: _________

AGREEMENT

I understand that this form is a public record. If a copy is requested, all exempt information contained herein

will be redacted. I hereby agree to indemnify and hold harmless the Office of Clerk & Comptroller and its staff

for any direct or indirect claims or damages that may arise in connection with this request for confidentiality.

Further, I accept responsibility for identifying the documents of record pertaining to me, my spouse, or my

child(ren). Additionally, a consequence of exercising this election is that documents evincing my ownership

interests in real property will not be available for viewing by the general public. In the event that I wish to

demonstrate my ownership interest in real property (e.g., to corroborate financial disclosure, to

facilitate title search, etc.), I will have to submit a written request for the release of the exempt

information to the Office of Clerk & Comptroller. The written request must be notarized and must specify

the information to be released and the party that is authorized to receive the information. Upon receipt of the

written request, the Office shall release the specified information to the party authorized to receive such

information. See F.S. §119.071(4)(d)4

I hereby request the removal of this information from the following official records documents:

Book _Page

Book ___________Page ___________

Book _________Page _______

Book ___________Page ___________

Book _________Page _______ Book _______Page ___________

I am aware that ONLY the information listed in Florida Statutes may be removed from public record.

___________ ________________________________

Date Signature

OR_F_Request for Redaction – Protected Class R100319

REQUEST FOR REDACTION OF INFORMATION PURSUANT TO F.S. 119.071

- PROTECTED STATUS

AGREEMENT

Request for Exemption from Public Records

In accordance with Florida Statute sections 119.071, 409.1678, 493; I ____________________________________ (Print Name)

am requesting that the Property Appraiser suppress information which would reveal my home address (location): including property

that I own in Pasco County that constitutes my home, the home of my spouse or children, or property in Pasco County for which I

am identified as an owner and for which my home address is used as the mailing address, as listed below:

A separate request must be completed for each parcel of property and must be identified by the Property Appraiser’s property

identification number or account number.

Parcel Identification Number ______________________________________________________________________________

Tangible Personal Property Account Number (if applicable) _____________________________________________________

Employment or circumstance that entitles me to the exemption from public records ___________________________________

Employee ID or Badge Number: ________________________ Driver’s License #: ___________________________________

Daytime Telephone Number: _________________________________ (work) _______________________ (Home or Mobile)

Email address: ________________________________________________________________________________________

Home Mailing Address: _________________________________________________________________________________

I herby verify that the above information to be true and correct and understand that information supplied or managed by other

agencies or offices are not included with this request. I also understand that once exempted from public records the information

regarding the above noted property will not be released without written authorization supplied to Property Appraiser’s Office in

person. I understand that the exemption from public record is not a method to escape creditors, avoid paying taxes, or other fees

assessed by government. The Property Appraiser is not responsible for lost or misdirected mail as the result of this request.

Upon the sale of the property all records will become a matter of public record.

Signature of person making request: ________________________________________________ Date: ___________________

Property Appraiser’s Office Use Only (refer to Florida Statute reading)

□ Law Enforcement, State Attorney/Public Defender/Judge, Firefighter, EMT/Medical technicians, Servicemember use code Q

□ Code Enforcement, Building Inspector, Administrator use code Y

□ Florida Retirement Admin, Dept of Health Inspectors, Impaired practitioner consultants use code Z

□ Protected victim of a Crime, Safe House, Foster Home use code C

-----------------------------------------------------------------------------------------------------------------------------------

□Additional property owned – mailing address does match home address use code A

□Additional property owned – mailing address does not match home address use code B

□Non-property owner – mailing address does not match home address use code N

WEST PASCO GOVERNMENT CENTER

NEW PORT RICHEY

TELEPHONE: 727-847-8151

FAX: 727-847-8013

EAST PASCO GOVERNMENT CENTER

14236 6TH STREET, SUITE 101

DADE CITY, FL 33523-3411

TELEPHONE: 352-521-4433

FAX: 352-521-4411

CENTRAL PASCO PROFESSIONAL CENTER

LAND O’ LAKE

TELEPHONE: 813-929

-2780

FAX: 813-929-2

784

PLEASE MAIL ALL CORRESPONDENCE TO : PASCO COUNTY PROPERTY APPRAISER - PO BOX 401, DADE CITY, FLORIDA 33526

PUBLIC OFFICIAL, LAW ENFORCEMENT AGENCY PERSONNEL AND OTHERS

PURSUANT TO SECTION 119.071, FLORIDA STATUTES

REQUEST TO WITHHOLD PERSONAL INFORMATION

This request form and corresponding privacy protection applies to current and former sworn or civilian law enforcement

personnel, public officials (active or former), servicemembers (active or former after 09/11/2001) and other identified

individuals, their spouses, children or dependents, who are eligible as outlined in Section 119.071, Florida Statutes. Those

who are eligible can request that the Department of Highway Safety and Motor Vehicles (DHSMV) withhold personal

information contained in their driver/identification, vehicle/vessel records maintained by this department. This privacy

protection does not apply to the mailing addresses maintained by this department. Mailing addresses may be released

for official business regarding motor vehicle or driver license information. Therefore, if you wish to ensure your

residential address is blocked and not displayed on your driver license/identification card, you may make an

appointment with your local driver license issuance office to provide an alternate mailing address and obtain a

replacement driver license/identification card.

The completion of this form is not mandatory but is made available as a convenience to individuals making this request and

to ensure that DHSMV has necessary information to update the appropriate records.

Please PRINT the personal information requested below. The information required to complete this form is located on the

Florida driver license or identification card of the requester. In all cases, the date of birth must match the date of birth on the

Florida driver license or identification card record. Complete additional forms or attach additional sheet as needed to include

eligible family members. We must have a statement of eligibility and documentation that indicates the eligibility.

Please return your request with documentation that indicates your eligibility to: Department of Highway Safety and

Motor Vehicles (DHSMV), 2900 Apalachee Parkway, MS 28, Tallahassee, Florida 32399 or email to

PublicOfficialBlock@flhsmv.gov

Personal Information of Individual Submitting Request

______________________________________________________________________________________________________________

FIRST NAME MIDDLE NAME LAST NAME

______________________________________________________________________________________________________________

STREET ADDRESS CITY STATE & ZIP CODE

Florida Driver License/Identification Card Number Date of Birth

Family Member(s) Driver License or Identification Card Information (spouse/child)

Florida Driver License/Identification Card Number Date of Birth

Note: See second page for a list of those who are eligible.

HSMV 96020 (Rev. 6/18)

Please refer to section 119.071, Florida Statutes for specific information regarding each exemption.

• Current or former sworn or civilian law enforcement personnel

• Current or former Correctional and correctional probation officers

• Current or former personnel of the Department of Children and Family Services who investigate cases of abuse,

neglect, exploitation, fraud, theft, or other criminal activities

• Current or former personnel of the Department of Health whose duties are to support the investigation of child abuse

or neglect

• Current or former personnel of the Department of Revenue or local governments whose responsibilities include revenue

collection and enforcement or child support enforcement

• Current or former certified firefighters

• Current or former justices of the Supreme Court, district court of appeal judges, circuit court judges, and county court

judges

• Current or former state attorneys, assistant state attorneys, statewide prosecutors, and assistant statewide prosecutors

• Current or former human resource, labor relations, or employee relations directors, assistant directors, managers, or

Assistant managers 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 United States attorneys and assistant United States attorneys

• Current or former United States Courts of Appeal judges, United States district judges, United States magistrate judges

• Current or former code enforcement officers

• Current or former guardian ad litem, as defined in s. 39.820

• Current or former juvenile probation officers, juvenile probation supervisors, detention superintendents, assistant

detention superintendents, juvenile detention officers, senior juvenile detention officers, juvenile detention officer

supervisors, house parents I and II, house parent supervisors, group treatment leaders, group treatment leader

supervisors, rehabilitation therapists, and social service counselors of the Department of Juvenile Justice

• Current or former public defenders, assistant public defenders, criminal conflict and civil regional counsel, and assistant

criminal conflict and assistant regional counsel

• Current or former county tax collectors

• Current or former servicemembers, who served after September 11, 2001

• Current or former impaired practitioner consultants retained by an agency or certain current or former employees of an

impaired practitioner consultant, under specified circumstances

• Current or former non-sworn investigative personnel of the Department of Financial Services

• Current or former emergency medical technicians or paramedics certified under chapter 401, F.S.

• Current or former employees of an agency’s office of inspector general or internal audit department whose duties

include auditing or investigation of waste, fraud, abuse, theft, exploitation, or other activities that could lead to criminal

prosecution or administrative discipline

• Current or former non-sworn investigative personnel of the Office of Financial Regulations Bureau of Financial Investigations whose duties include

the investigation of fraud, theft, or other related criminal activities, or state regulatory requirement violations

• Current or former directors, managers, supervisors, and clinical employees of a Child Advocacy Center (CAC) and Child Protection Team (CPT)

• Current or former public guardians and employees with fiduciary responsibility, as defined in s. 744.21031, F.S.

• Current or former directors, managers, supervisors, nurses, and clinical employees of government owned addiction treatment facilities

HSMV 96020 (Rev. 6/18)