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 ____ former ____ spouse of a current or ____ spouse of a former ____ Law enforcement employee (state type: __________________________) ____ Department of Children and Families investigative employee whose duties include: ____ abuse ____ fraud ____ neglect ____ theft ____ exploitation ____ 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: __________________________) _____ Military Armed Forces (current & former member _____ Additional Individuals to exempt (Spouse & Dependents) American LegalNet, Inc. www.FormsWorkFlow.com 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 List of documents that pertain to me ___________________________________________ ___________________________________ ___________________________________________ __________________________________ ___________________________________________ __________________________________ ___________________________________________ __________________________________ ___________________________________________ __________________________________ ___________________________________________ _________________________________ ___________________________________________ _________________________________ ____________________________________________ _________________________________ _____________________________________________ _________________________________ ______________________________________________ ______________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com