HomeMy WebLinkAboutPresley_Public Records Exemption Request4 IFLORIDA DEPARTMENT 1
PUBLIC RECORDS EXEMPTION REQUEST(REv os/Zoz><j
Florida law allows certain persons to request that an ap-encv not publicly disclose specific identification and/or location information contained in anv
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 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 here0 )
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 0.
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):
ED Elcurrentor former
spouse of a current or 11 spouse of a former
child of a current or El 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(4Xd)2.t)
Code Enforcement Officer (s. I I9.071(4Xd)2.i)
County Tax Collector (s. 119.071(4Xd)2.n)
Dept. of Business and Professional Regulation -investigators and
inspectors (s. 119.07l(4Xd)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(4Xd)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. 119.07l(4Xd)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. 119.07 ] (4)(d)2.o)
Dept. of Revenue personnel or local government personnel whose
duties relate to revenue collection and enforcement or child support
enforcement. (s. 119.07l(4Xd)2.a)
Domestic violence centers, certified under Chapter 39, F.S., staff and
domestic violence advocates as defined in s. 90.5036(l)(b), F.S. (s.
119.07] (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(4Xd)2.q)
Firefighter certified in compliance with s. 633.408, F.S.
S.119.07l(4Xd)2.d)
Guardianad litem (s. 119.07l(4Xd)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(4Xd)211) Impaired
practitioner consultants whose duties result in a determination
of a person's skill and safety to practice a licensed profession (
s. 119.07 1 (4Xd)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 county court, or justice
of the Florida Supreme Court (s. 119.071(4Xd)2.c)
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 l9.071(4xd)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 IL 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)
aLaw enforcement personnel including correctional officers and
correctional probation officers (s. 119.071(4xd)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(4xd)2.c.)
Printed Name: Kevin Presley
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. 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 (850-414-3990) about eligibility for
separate Address Confidentiality Program. See s. 741.465, Fla. Stat]
Other (list applicable statute):
11-01-1974 321-377-4035
Date of Birth: Phone Number:
Home Address:
1371 Ellis Fallon Loop, Oviedo, FL 32765
Signature: Date:
10-12-2023
suant to Section 119.071(4)(d)3., F.S., your request must be notarized. The requestor hereby swears or affirms, under penalty of
ury, that the information contained in the foregoing public record exemption form is true and correct.
REQUIRED NOTARIZATION SECTION
STATE OF FLORIDA
COUNTY OF:5e4 L1NA—
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 0Ck6)9<r- , 20 2-5 by
L l 19reS
v personally known to me OR
produced the following identification:
who is:
ti yv v • MELISSA L BUCHMAN
Notary Public - State of Florida Signature of Notary Public - State of Florida
Commission # HH 318008
oF My Comm. Expires Dec 17, 2026
Bonded through National Notary Assn.
PW
Print, Type, or Stamp Commissioned Name of Notary Public