STATE OF CALIFORNIA
REQUEST FOR NONDISCLOSURE OF EMPLOYEE HOME ADDRESS
STD. 677 (Rev. 10/2019)
PLEASE TYPE OR USE BALL POINT PEN - PRINT CLEARLY
NAME (Last, First, Middle Initial) SOCIAL SECURITY NUMBER
Pursuant to Government Code Section 6254.3:
(a)
The home addresses, home telephone numbers, personal cellular telephone numbers, and birth dates of all employees of a public agency shall not be deemed
to be public records and shall not be open to public inspection, except that disclosure of that information may be made as follows:
(1) To an agent, or a family member of the individual to whom the information pertains.
(2)
To an officer or employee of another state agency
when necessary for the performance of its official duties.
(3)
To an employee organization pursuant to regulations and decisions of the Public Employment Relations Board, except that the home addresses and
any phone numbers on file with the employer of
employees performing law enforcement-related function, and the birth date of any employee,
shall
not be disclosed.
(4)
To an agent or employee of a health benefit plan providing health services or administering claims for health services to public agencies and their
enrolled dependents, for the purpose of providing the health services or administering claims for employees and their enrolled dependents.
(b)
(1)
Unless used by employee to conduct public business, or necessary to identify a person in an otherwise discloseable communication, the personal email
addresses of all employees of a public agency shall not be deemed to be public records and shall not be open to public inspection, except that
disclosure of that information may be made as specified in paragraphs (1) to (4), inclusive, of subdivision (a).
(c)
Upon written request of any employee, a public agency shall not disclose the employee’s home address, home telephone number, personal cellular
telephone number, personal email address, or birth date pursuant to paragraph (3) of subdivision (a) and an agency shall remove the employee’s home
address, home telephone number, and personal cellular telephone number from any mailing list maintained by the agency, except if the list is used
exclusively by the agency to contact the employee.
CHECK APPROPRIATE BOX
I request that my home address not be disclosed as provided by Government Code Section 6254.3(b). I understand that my home address
can be disclosed to specified individuals or organizations under Government Code Sections 6254.3.
I cancel my previous request of having my home address not be disclosed.
PRIVACY NOTICE
The Information Practices Act of 1977 (California Civil Code Section 1798.17) and the Federal Privacy Act (5 USC 552a, subd. (e)(3)) require this notice to be provided when
collecting personal information from individuals. Information requested on this form, which includes the social security number, is used for the purposes of identification and the
address withhold processing. Furnishing the requested information on this form is mandatory. Failure to provide the mandatory information may result in the address withhold
action not being processed or being processed incorrectly.
Legal references authorizing the maintenance of this information include: Federal Internal Revenue Code (26 USC Sections 3402(a), 6011, 6051, and 6109) and the regulations
thereto; and California Government Code Sections 12470 through 12479 and 16391 through 16395; delegated authority from the State Personnel Board; and delegated authority
from the Trustees of the California State University.
Employees have the right to review their own personal information maintained by the State Controller’s Office unless access is denied by law. Contact: Personnel/Payroll Services
Division, State Controller’s Office, P.O. Box 942850, Sacramento, CA 94250-5878.
EMPLOYEE SIGNATURE DATE SIGNED
PERSONNEL OFFICE USE ONLY
REVIEWER’S SIGNATURE TELEPHONE NUMBER
( )
DATE REVIEWED
AGENCY UNIT KEYED BY DATE KEYED
(2)
This subdivision shall not be construed to limit the public’s right to access the content of an employee’s personal email that is used to conduct public
business, as decided by the California Supreme Court in City of San Jose v. Superior Court (2017) 2 Cal. 5th 608.
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