HomeMy WebLinkAboutMolina_Public Records Exemption Request_2024Florida law allows certain persons to request that an agency not
of its agency records. Please refer to sections 119.071(2)0), (4)(
protection which may include home address, phone numbers, p
or daycare care facility, and date of birth.
ly disclose specific identification and/or location information contained in any
f (5)(i), 265.605, and 267.17, Fla Stat.; or other applicable statute for scope of
time of spouse and/or children, and their place of employment, and/or school
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 ofbirth, 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 individu 1 covered under Section 119.071, F.S., as, check the appropriate item (only one):
intent or former
F1spouse 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.$)
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)2.0
CountyTax Collector(s. 119.071(4)(d)2.n) 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. I I9.071(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) 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. 119.07I(4Xd)2.o) 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.a) Domestic
violence centers, certified tinder 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.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. 119.071(4)(d)2.q) Firefighter
certified in compliance with s. 633.408, F.S. s.
119.07I(4Xd)2.d) Guardian
ad litem (s. I I9.071(4)(d)2j) rn/
1-luman resource, labor relations, or employee relations director, M
assistant director, manager or assistant manager of any local government
agency or water management district s.
119.071(4)(d)2. h) ElImpaired
practitioner consultants whose duties result in a determinationofaperson'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. 119.071(4Xd)2.r) Judge -
district court of appeal, circuit court and wanly court, or justice
of the Florida Supreme Court (s. 119.071(4)(d)2.e)
E] Judicial or quasi-judicial officer (general and special magistrate, judge of compensation claims, administrative lawjudge of the
Division of Administrative Hearings, and child support
enforcement hearing officer) (s. 119.071(4)(d)2.g)
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 It, 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.)
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. appellatejudge, U.S district
courtjudge 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(5xi)
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):
Name: axl .a,>Q tl i I j / k Date of Birth: —I 25-7 Phone Number:
Address: 5 5n 5ucjo, r `I
Signature:
K
Pursuant to Section 119.071(4)(d)3., F.S., your request must be notarized. The requestor hereby swears or affirms, under penalty of
oeriury, that the information contained in the foregoing public record exemption form is true and correct.
REQUIRED NOTARIZATION SECTION
STATE OF FLORIDA
COUNTY OF 5a rn t nG I
The
foregoing
Public Records Exemption Request was sworn to (or affirmed) and subscribed before me by means of
Q"physical presence or online notarization, this 20day of 20 vZ V-, by 1) '
iltk nmn 111iiYILh. who is: personally
known to me OR produced
the following identification: JADE
SYMONE ANDEFSON Notary
Public • State of Florida Commission
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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:
550 svgrzr Al/l? 64 3/lo Oviedo , FL 32765
2. Are you now o have you ever been listed on the Division of Corporations' records as:
a. an officer or director of a corporation? Yes No Q
b. a managing member or manager of a limited liability company? Yes No
c. a general partner in a limited partnership? Yes No Q
d. an owner of a fictitious name? Yes E] No
e. a partner in a general partnership? Yes [—] No Q
f. a notary? Yes FEI' No 0
g. an owner of a trademark registration Yes Q 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 0 No 11Gf
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 arecord with a missing principal place of business for these entities.
Name/Names of entity or registration:
B-os5 LAj-!Si" ices G T VAs4m44 LLs L( 2&
WO-1 TZoria 3<36Z5 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.