Fillable Confidential Records Request - confidential_form

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Confidential Records Request - confidential_form

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U:\Admin\docs\confidential_form.doc Sept. 2011
PALM BEACH COUNTY
PLANNING, ZONING & BUILDING DEPARTMENT
CONFIDENTIAL RECORD REQUEST
SECTION 119.07, FLORIDA STATUTES
Permit Owner’s Name
(PLEASE PRINT)
*** In accordance with Florida State Statute 119.07(6)(i)(1), Planning, Zoning & Building may only remove
your home address from permit records. ***
Please indicate type of position held:
[ ] Active Law Enforcement personnel
[ ] Former/Retired Law Enforcement
[ ] Correctional or Correctional Probation (LEO)
[ ] Retired Correctional/Probation
[ ] HRS - Investigative - Abuse, Neglect, Exploitation, Fraud, Theft, (all criminal activities)
[ ] Firefighters - Certified 633.35
[ ] Justice - Supreme Court, District Court of Appeals, Circuit Court and County Judges Department of
Revenue
[ ] Government Personnel (Responsible for Revenue Collection & Enforcement including child support)
[ ] Current/Former Code Enforcement Officers
[ ] State Attorneys and State Prosecutors
[ ] Victim of Sexual Battery, Aggravated Child Abuse, Aggravated Stalking, Harassment, Aggravated
Battery, or Domestic Violence (Must attach Official Verification that an applicable crime has
occurred.)
I hereby request my home address listed on records in the custody of the Planning, Zoning & Building
Department be held in confidence, subject to the open Government Sunset Review Act, in accordance
with Florida Statutes, Section 119.07.
HOME ADDRESS:
CITY: STATE: ZIP:
PROPERTY CONTROL NUMBER (PCN) - - - - - -
IF YOU MOVE YOU MUST RE-APPLY FOR CONFIDENTIALITY
Are you re-applying for confidentiality with Planning, Zoning & Building? Yes ___ No ___
If yes, what address did you have as a confidential record previously?
I am currently/formerly employed with: _______________________________________________________________
Badge #: ____________________ Certification: __________________
Signed:
Date:____________________________
Please return this completed form to: Palm Beach County Planning, Zoning & Building, Building Division, 2300 N Jog Road, West
Palm Beach FL 33411. For questions about this form please call (561) 233-5100.
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Completed 10 June 2020

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