HomeMy WebLinkAboutCaruso, Mark Public Records Exemption Form.pdfFlorida 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)0), (4)(d), and (5)(i), 265.605, and 267.17, Fla. Stat., or other applicable statute for scope of
protection which M#3Linclude 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 City of Winter Springs, please complete the form and return to:
City of Winter Springs, c/o City Clerk's Office, 1126 East State Road 434, Winter Springs, FL 32708. For more information, contact
407-327-6560.
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 Q)
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 ttte 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.$)
Child advocacy center, meeting the standards set forth in Chapter
39, F.S., directors, managers, srfpervisors, 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.n)
®Dept. of Business and Professional Regulation -investigators and inspectors (s. 119.071(4)(d)2.m)
QDept. of Children and Family Services personnel whose duties
involve investigation of abuse, neglect, exploitation, fi•aud, theft,
or other criminal activities (s. 119.071(4)(d)2.a)
❑ Dept. of Financial Services investigative personnel whose duties
include the investigation of fiaud, 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)
❑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 (s. 119.071(4)(d)2.o)
Dept, of Revenue persormel or local govenmrent persomrel whose
duties relate to revenue collection and enforcement or child support
enforcement. (s. 119.071(4)(d)2.a)
Domestic violence centers, certified under Chapter 39, F.S., staff and
❑
domestic violence advocates as defined ins. 90.5036(1)(b), F.S. (s.
119.071(4)(d)2.u)
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. I (9.071(4)(d)2.q)
Firefighter certified in compliance with s. 633.408, F.S.
(s. I19.071(4)(d)2.d)
❑ Guardian ad litem (s. 119.071(4)(d)2.j)
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)2.1i)
QImpaired 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.p)
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. I I9.071(4)(d)2.r)
®Judge -district court of appeal, circuit court and county court, or
justice of the Florida Supreme Court (s. 119.071(4)(d)2.e)
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. I I9.071(4)(d)2.g)
Juvenile probation officer, juvenile probation supervisor,
detention superintendent, assistant detention superintendent,
seniorjuvenile detention officer, juvenile detention officer
supervisor, juvenile detention officer, house parent I and 11, 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.k)
Law enforcement personnel including correctional officers and
correctional probation officers (s. 119.071(4)(d)2.a)
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.)
N
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Address:
Prosecutor (state attorney, assistant state attorney, statewide
prosecutor, assistant statewide prosecutor) (s. 119.071(4)(d)2.f)
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)2.1)
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. I I9.071(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 (850414-3990) about eligibility for
separate Address Confidentiality Program. See s. 741.465, Fla. Stat]
Other (list applicable statute):
of Birth: — Phone Number:�
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Date: Z4 �� �' �2•
zt to Section 119.071(4)(d)3., F.S., your request must be notarized. The requestor hereby swears or affirms, under penalty of
that the information contained in the foregoing public record exemption form is true and coiTect.
REQUIRED NOTARIZATION SECTION
ATE OF FLORIDA
NTY OF hem � no I�
e foregoing Public Records Exemption Request was sworn to (or affirmed) and subscribed before me by means of
[�, physical presence or ❑online notarization, this � �fl, Zy , by
.who is:
rsonally known to me OR
uced the following identification:
Notary Public State of Florida
Christian D Gowan
lift My Commission HH 433379
Expires 9/16/2027
Signature of Notary Public -State of Florida
Notary Public State of Florid
Christian D Gowen
till My Comn11881On HH 433379
Expires 0/16/2027
ic
Print, Type, or Stamp Commissioned Name of Notary Publ