REQUEST FOR CONFIDENTIALITY SENT TO: Bill Kinsaul Clerk of Circuit Court P.O. Box 2269 Panama City, FL 32402 I am filing this request for confidentiality in the Bay County Official Records in accordance with F.S. 119.071(4). I hereby swear or affirm that the following information is true and correct: I attest that I am an individual covered under F. S. 119.071(4). I am a ______ current or ______spouse of a current or ________ former _________spouse of a former _______Law enforcement employee(state type:___________________) _______Department of Children and Families investigative employee whose duties include: _____abuse _____neglect _____exploitation _____fraud _____theft _____other criminal activities _____Judge or Justice (state type:____________________) _____General, special magistrate or other administrative law judge or hearing officer (state type___________________________) ____Depart. Of Revenue or Local government employee responsible for: ____revenue collection and enforcement ____child support enforcement ____State Attorney or State Prosecutor (state type:_____________________) ____Firefighter ____Code Enforcement Officer or Inspector (state type:_________________) ____Local government or water district human resource professional (state type: __________________________) Continue on back American LegalNet, Inc. www.FormsWorkflow.com P. 2 Request for Confidentiality: Please print clearly or use a typewriter to complete the following lines: My full name is: __________________________________________________________ Other names that I many have used: ___________________________________________ Home address (including city, state, and zip code):________________________________ Social Security Number:_____________________________________________________ Telephone Number:_________________________________________________________ The information provided on this request for confidentiality is itself to be kept confidential. The information may only be used by the Bay County Clerk’s staff in order to process my request for confidentiality. Further I agree to personally identify those documents of record pertaining to me (attach list). Signature of Individual: _____________________________ Date: ___________________ State of Florida County of __________________ Sworn to (or affirmed ) and subscribed this __________ day of _______________, ______ By_______________________________________________________ Personally known________________ or produced identification _______________ Type of identification produced _________________________________________ Signature of Notary ___________________________ American LegalNet, Inc. www.FormsWorkflow.com