PUBLIC RECORDS EXEMPTION REQUEST
to the FLORIDA DEPARTMENT OF STATE
Florida law allows eligible persons and their employing agencies to request in writing that a non-employing agency maintain as exempt
from public disclosure certain identification and/or location information contained in records within the agency’s custody. If an
employing agency is requesting for the employee, add agency name, and requester’s name and title, to the signature line.
NOTE: The officer, employee, justice, judge, other person entitled to the exemption, or employing agency of the designated employee,
must submit this written request directly to a custodial agency in order for the agency to maintain the exemption for the records in its
custody. For records in the custody of the Department of State, please return this completed form or a written request directly to:
Department of State, Attn: Public Records Officer, R.A. Gray Building, Ste. 100, 500 S. Bronough St., Tallahassee, FL 32399. To have
an exemption maintained in the records in the custody of any other agency, please contact that agency directly for information on how
to make a written request.
If your spouse and/or children are subject to your exemption (not applicable for victim* of battery, abuse, harassment, or stalking
or for participant* in address confidentiality program), please check here ☐ and attach a page with the name, date of birth, and
relationship of each to assist in identifying each person in any public records within the custody of the agency.
To facilitate processing your request for any of records in the custody of the Division of Corporations, please complete the Addendum
for Exemption of Public Disclosure on the next page. If not applicable, check here ☐.
I hereby request exemption maintenance by your agency based on the following category/categories for which I qualify:
☐ Code Enforcement Officer.
☐ Dept. of Business and Prof. Reg. investigators and inspectors. †
☐ Dept. of Children and Family Services personnel whose duties
involve investigation of abuse, neglect, exploitation, fraud, theft, or
other criminal activities.
☐ Dept. of Health personnel whose duties support the investigations
of child abuse or neglect.
☐ Dept. of Health personnel whose duties include, or result in, the
determination/adjudication of eligibility for social security disability
benefits, investigation/ prosecution of complaints filed against health
care practitioners, or inspection of health care practitioners or health
care facilities licensed by the Dept. of Health. †
☐ Dept. of Financial Services personnel whose duties include the
investigation of fraud, theft, workers’ compensation coverage
requirements and compliance, other related criminal activities, or state
regulatory requirement violations.
☐ Dept. of Revenue personnel or local government personnel whose
duties include revenue collection and enforcement or child support
enforcement.
☐ Emergency medical technicians or paramedics certified under
chapter 401, F.S. †
☐ Firefighter certified in compliance with s. 633.408, F.S.
☐ Guardian ad litem as defined in s. 39.820, F.S. †
☐ Human resource, labor relations, or employee relations director;
assistant director, manager, or assistant manager of any local
government agency or water management district whose duties include
hiring and firing employees, labor contract negotiation, administration,
or other personnel-related duties.
☐ Impaired practitioner consultant, retained by an agency, whose
duties result in determination of person’s skill and safety to practice
licensed profession (includes consultant’s employees). †
☐ Justice of Florida Supreme Court; or judge of district court of
appeal, circuit court, or county court.
☐ County Tax Collector. †
☐ Inspector general or internal audit dept. personnel whose duties
include auditing/investigating waste, fraud, abuse, theft, exploitation, or
activities that could lead to criminal prosecution or admin. discipline. †
☐ Judicial or quasi-judicial officer (general/special magistrate, judge of
compensation claims, administrative law judge of the Div. of Admin.
Hearings, and child support enforcement hearing officer). †
☐ Juvenile probation officers, juvenile probation supervisors, detention
superintendents, assistant detention superintendents, juvenile justice
detention officers I/II, juvenile justice detention officer supervisors,
juvenile justice residential officers, juvenile justice residential officer
supervisors I II, juvenile justice counselors, ju
venile justice counselor
supervisors, human services counselor administrators, senior human
services counselor administrators, rehabilitation therapists, and social
services counselors of the Dept. of Juvenile Justice.
☐ Law enforcement personnel, including civilian personnel,
correctional officers and correctional probation officers.
☐ Prosecutor (state attorney, assistant state attorney, statewide
prosecutor, assistant statewide prosecutor).
☐ Public defenders and criminal conflict and civil regional counsel
(includes assistant public defenders, assistant criminal conflict and
assistant civil regional counsel).
☐ Member of U.S. Armed Forces, reserve component of U.S. Armed
Forces, or National Guard who served after 9/11/2001. †
☐ U.S. Attorney or Assistant U.S. Attorney, U.S. circuit judge, U.S
district judge, or U.S. magistrate judge. †
☐ Victim* of sexual battery, aggravated child abuse,
aggravated
stalking, harassment, aggravated battery, or domestic violence—
Please attach official verification that crime occurred—Exemption
for 5 years from date of this request.
☐ Certified Participant* in Address Confidentiality Program under
s. 741.403, F.S.—Exemption applies only to participant’s name,
address, and telephone number in voter registration and voting
records—Please attach copy of certification or renewal.
Date of Birth: Phone Number:
Printed Name:
Home Address:
Signature (and Title, if app.) of Requester:
†
Date:
† If specially indicated category selected, person also certifies, by signature herein, that he or she has made reasonable efforts to
protect information from being publicly accessible through other means available to the public.
Form DOS-119 Rev. 07/19
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