Fillable REQUEST TO WITHHOLD PERSONAL INFORMATION PUBLIC OFFICIAL, LAW (Florida)

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REQUEST TO WITHHOLD PERSONAL INFORMATION PUBLIC OFFICIAL, LAW (Florida)

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PUBLIC OFFICIAL, LAW ENFORCEMENT AGENCY PERSONNEL AND OTHERS
REQUEST TO WITHHOLD PERSONAL INFORMATION
PURSUANT TO SECTION 119.071, FLORIDA STATUTES
This request form and corresponding privacy protection applies to current and former sworn or civilian law
enforcement personnel, public officials (active or former), servicemembers (active or former after 09/11/2001) and
other identified individuals, their spouses, children or dependents, who are eligible as outlined in Section 119.071,
Florida Statutes.
Those who are eligible can request that the Florida Department of Highway Safety and Motor Vehicles (FLHSMV)
withhold personal information contained in their driver/identification, vehicle/vessel records maintained by this
department. FLHSMV maintains both a residential address and mailing address for each individual. This privacy
protection applies only to the residential address but not the mailing address. If you do not provide FLHSMV
with a separate mailing address, your residential address will be listed as your mailing address. Mailing
addresses are routinely released for official business regarding motor vehicle or driver license information.
Therefore, if you wish to ensure your residential address is blocked and not displayed on your driver
license/identification card, you may make an appointment with your local driver license issuance office to
provide a separate mailing address and obtain a replacement driver license/identification card.
Please PRINT the personal information requested below. The information required to complete this form is located
on the Florida driver license or identification card of the requester. In all cases, the date of birth must match the date
of birth on the Florida driver license or identification card record. Complete additional forms or attach additional sheet
as needed to include eligible family members. We must have a statement of eligibility and documentation that
indicates the eligibility.
Please return your request with documentation indicating your eligibility to: Florida Department of Highway
Safety and Motor Vehicles (FLHSMV), 2900 Apalachee Parkway, MS 28, Tallahassee, Florida 32399 or email
to: PublicOfficialBlock@flhsmv.gov
Please indicate statutory basis for exemption. See Page 3: _________________________________
Personal Information of Individual Submitting Request
______
FIRST NAME MIDDLE NAME LAST NAME
STREET ADDRESS CITY STATE & ZIP CODE
Florida Driver License/Identification Card Number Date of Birth
Family Member/Members (spouse/child) Driver License or Identification Card Information
1. _____
Florida Driver License/Identification Card Number Date of Birth
2. _ _____
Florida Driver License/Identification Card Number Date of Birth
3. _____
Florida Driver License/Identification Card Number Date of Birth
Under penalty of perjury, I affirm that I qualify for the exemption claimed above pursuant to section 119.071, Florida
Statutes
_____________________________________ _________________________________________________________
Print/Type/Stamp Requestor’s Name Signature of Requestor
HSMV 96020 (Revised 07/2021)
Sworn (or affirmed) and subscribed before me by means of physical presence or online notarization
this ______ day of _______________________, 20__ _, by ________________________________________
Personally Known or Produced Identification (ID) Type of ID Produced: _________________________
Print/Type/Stamp Commissioned Notary Name Signature of Notary Public
HSMV 96020 (Revised 07/2021)
Please refer to section 119.071, Florida Statutes for specific information regarding each exemption.
• Current or former sworn or civilian law enforcement personnel, including correctional and correctional probation officers,
personnel of Department of Children and Families whose duties include the investigation of abuse, neglect, exploitation, fraud,
theft, or other criminal activities, personnel of the Department of Health whose duties are to support the investigation of child
abuse or neglect, and personnel of the Department of Revenue or local governments whose responsibilities include revenue
collection and enforcement or child support enforcement
• Current or former non-sworn investigative personnel of the Department of Financial Services
• Current or former non-sworn investigative personnel of the Office of Financial Regulation, Bureau of Financial Investigations
whose duties include the investigation of fraud, theft, other related criminal activities, or state regulatory requirement violations
• Current or former certified firefighters
Current or former justices of the Supreme Court, district court of appeal judges, circuit court judges, and county court judges
• Current or former state attorneys, assistant state attorneys, statewide prosecutors, and assistant statewide prosecutors
• Current or former general magistrates, special magistrates, judges of compensation claims, administrative law judges of the
Division of Administrative Hearings, and child support enforcement hearing officers
• Current or former human resource, labor relations, or employee relations directors, assistant directors, managers, or
assistant managers 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
• Current or former code enforcement officers
• Current or former guardian ad litem, as defined in s. 39.820
• Current or former juvenile probation officers, juvenile probation supervisors, detention superintendents, assistant detention
superintendents, juvenile justice detention officers I and II, juvenile justice detention officer supervisors, juvenile justice
residential officers, juvenile justice residential officer supervisors I and II, juvenile justice counselors, juvenile justice
counselor supervisors, human services counselor administrators, senior human services counselor administrators,
rehabilitation therapists, and social services counselors of the Department of Juvenile Justice
• Current or former public defenders, assistant public defenders, criminal conflict and civil regional counsel, and assistant
criminal conflict and assistant regional counsel
• Current and former investigators or inspectors of the Department of Business and Professional Regulation
• Current or former county tax collectors
• Current or former personnel of the Department of Health whose duties include, or result in, the determination or adjudication
of eligibility for social security disability benefits, the investigation or prosecution of complaints filed against health care
practitioners, or the inspection of health care practitioners or health care facilities license by the Department of Health
• Current or former impaired practitioner consultants retained by an agency or current or former employees of an impaired
practitioner consultant whose duties result in a determination of a person's skill and safety to practice a licensed profession
• Current or former emergency medical technicians or paramedics certified under chapter 401, F.S.
auditing or investigation of waste, fraud, abuse, theft, exploitation, or other activities that could lead to criminal prosecution or
administrative discipline
• Current or former directors, managers, supervisors, nurses, and clinical employees of government owned addiction
treatment facilities
• Current or former directors, managers, supervisors, and clinical employees of a child advocacy center and members of a
child protection team whose duties include supporting the investigation of child abuse or sexual abuse, child abandonment,
child neglect, and child exploitation or to provide services as part of a multidisciplinary case review team
• Current or former United States attorneys
,
assistant United States attorneys
,
United States Courts of Appeal judges, United
States district judges, and
United States magistrate judges
• Current or former servicemembers, who served after September 11, 2001
• Current or former public guardians and employees with fiduciary responsibility, as defined in s. 744.21031, F. S.
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REQUEST TO WITHHOLD PERSONAL INFORMATION PUBLIC OFFICIAL, LAW (Florida)

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Completed 20 April 2022

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