DFS-H2-1500 69B-221.155, F.A.C.
(10/17)
Privacy Statement
Pursuant to the Privacy Act of 1974, 5 U.S.C. § 552a, the State is responsible for informing you whether
disclosure of your social security number is mandatory or voluntary, by what statutory or other authority your
social security number is solicited, and what uses will be made of your social security number. Under §
119.071(5)(a)2.a., F.S., a state agency may collect your social security number if the collection is:
(I) specifically authorized by law; or
(II) imperative for the performance of the agency’s duties and responsibilities as prescribed by law.
Disclosure of your social security number on this form is mandatory pursuant to the Welfare Reform Act, 42
U.S.C. § 666, and §§ 626.171(2)(a) and (7), 626.231(2)(a), 626.541(1), and 626.9953(3)(a)
and (7), F.S.
The purposes for the requested information are to verify the identity of an applicant for licensure, to conduct
criminal and disciplinary history background checks, and to determine if the applicant lacks the fitness or
trustworthiness to engage in the business of insurance. Your social security number is confidential and
exempt from the disclosure requirements of § 119.07(1), F.S., and § 24(a), Article I of the Florida
Constitution and will not be used for any purpose other than the purposes provided herein, or as otherwise
authorized under § 119.071(5)(a), F.S.
A copy of this Privacy Statement is provided to you as required by § 119.071(5)(a)3., F.S.
