STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS OFFICE OF THE JUDGES OF COMPENSATION CLAIMS Florida law allows certain persons to request that an agency not publicly disclose their specific identification and/or location information in any of its agency records. See for example, Fla. Stat. § 119.071 (2)(j), (4)(d) and (5)(i), for applicable exemption and scope of exemption. If eligible, submit completed form via e-filing at http://www.jcc.state.fl.us/eJCC/EFile.aspx, or if you are Pro Se you may paper file at 1180 Apalachee Parkway, Suite A, Tallahassee, FL 32301. For more information, please contact 850-487-1911. I hereby request the exemption (check applicable exemption category) for the person named below: ____Code Enforcement Officer ____Dept. of Children and Family Services personnel with investigative duties involving abuse, neglect, exploitation, fraud, theft, or other criminal activities. ____Dept. of Revenue personnel or local government personnel with duties relating to revenue collection and enforcement or child support enforcement. ____Firefighter certified in compliance with s.633.35, F.S. ____Guardian ad litem (By signature below, it is certified that the person made "reasonable efforts to protect such information from being accessible through other means available to the public.") ____Human resource, labor relations, or employee relations director, assistant director, manager or assistant manager of any local government agency or water management district(whose duties include hiring and firing employees, labor contract negotiation, administration, or other personnelrelated duties.) ____Judge or justice of the Florida Supreme Court, district courtof appeal, circuit court and county court below, it is certified that the person made "reasonable efforts to protect such information from being accessible through other means available to the public.") ____Judicial or quasi-judicial officer (general and special magistrate, judge of compensation claims, administrative law judge of the Division of Administrative Hearings, and child support enforcement hearing officer) (By signature below, it is certified that the person made "reasonable efforts to protect such information from being accessible through other means available to the public.") ____Juvenile probation officer, juvenile probation supervisor, detention superintendent, assistant detention superintendent, senior juvenile detention officer, house parent I and II, house parent supervisor, group treatment leader supervisor, group treatment leader, group treatment leader supervisor, rehabilitation therapist, and social services counselor of the Dept. of Juvenile Justice. ____Law enforcement personnel including correctional officers and correctional probation officers. ____Prosecutor (state attorney, assistant state attorney, statewide prosecutor, assistant statewide prosecutor) ____Public defenders and criminal conflict and civil regional counsel (includes assistant public defenders, assistant criminal conflict and assistant civil regional counsel.) ____U.S. attorney or assistant attorney, U.S. appellate judge, U.S. district court judge and U.S. magistrate (by signature below, it is certified that the person made "reasonable efforts to protect information from being accessible through other means available to the public.") ____Other (list applicable statute):_______________ Printed Name:_____________________________ Date of Birth________________________ Last 4 digits of SSN or Fla DL #:__________________________________________________ This field is optional but may help to identify your records among other similarly named persons). Resident Address (City, State, Zip):_______________________________________________ Signature__________________________________Date_______________________________ American LegalNet, Inc. www.FormsWorkFlow.com