REQUEST FOR PROTECTED ADDRESS
(F/N Occupant)
Pursuant to Florida Statute 119.071(4) (d) 1., the following are eligible for “protected address”
status. Upon request, home addresses and telephone numbers will be kept confidential:
Current or former state attorneys, assistant state attorneys, statewide prosecutors, or assistant
statewide prosecutors, their spouses and children.
Active or former law enforcement personnel, including correctional and correctional probation
officers, their spouses and children.
Personnel of the Department of Health and Rehabilitative Services whose duties include the
investigation of abuse, neglect, exploitation, fraud, theft, or other criminal activities, their
spouses and children.
Personnel of the Department of Revenue or local governments whose responsibilities include
the revenue collection and enforcement or child support enforcement, their spouses and
children.
Firefighters, certified in compliance with F.S. 633.35, their spouses and children.
Justices of the Supreme Court, district court of appeal judges, circuit court judges, and county
court judges, their spouses and children.
County and municipal code inspectors and code enforcement officers.
I qualify to be registered with “protected address” status because:
_____________________________________________________________________________________
Account #: ______________________
Print Name: ______________________________________________________
Service Address: ______________________________________________________
City, State, Zip Code: ______________________________________________________
Telephone #: ______________________
Date: ______________________
Please print this form after completing and mail it to 14 S. Fort Harrison Ave,
Clearwater, FL 33756. Please put to Attention: Collections.
