PUBLIC RECORDS EXEMPTION REQUEST

to the FLORIDA DEPARTMENT OF STATE
Florida law allows eligible persons and their employing agencies to request in writing that a non-employing agency maintain as exempt
from public disclosure certain identification and/or location information contained in records within the agency’s custody. If an
employing agency is requesting for the employee, add agency name, and requester’s name and title, to the signature line.
NOTE: The officer, employee, justice, judge, other person entitled to the exemption, or employing agency of the designated employee,
must submit this written request directly to a custodial agency in order for the agency to maintain the exemption for the records in its
custody. For records in the custody of the Department of State, please return this completed form or a written request directly to:
Department of State, Attn: Public Records Officer, R.A. Gray Building, Ste. 100, 500 S. Bronough St., Tallahassee, FL 32399. To have
an exemption maintained in the records in the custody of any other agency, please contact that agency directly for information on how
to make a written request.
If your spouse and/or children are subject to your exemption (not applicable for victim* of battery, abuse, harassment, or stalking
or for participant* in address confidentiality program), please check here ☐ and attach a page with the name, date of birth, and
relationship of each to assist in identifying each person in any public records within the custody of the agency.
To facilitate processing your request for any of records in the custody of the Division of Corporations, please complete the Addendum
for Exemption of Public Disclosure on the next page. If not applicable, check here ☐.
I hereby request exemption maintenance by your agency based on the following category/categories for which I qualify:
 
☐ Code Enforcement Officer. ☐ County Tax Collector. †
☐ Dept. of Business and Prof. Reg. investigators and inspectors. † ☐ Inspector general or internal audit dept. personnel whose duties
include auditing/investigating waste, fraud, abuse, theft, exploitation, or
☐ Dept. of Children and Family Services personnel whose duties
activities that could lead to criminal prosecution or admin. discipline. †
involve investigation of abuse, neglect, exploitation, fraud, theft, or
other criminal activities. ☐ Judicial or quasi-judicial officer (general/special magistrate, judge of
compensation claims, administrative law judge of the Div. of Admin.
☐ Dept. of Health personnel whose duties support the investigations
Hearings, and child support enforcement hearing officer). †
of child abuse or neglect.
☐ Juvenile probation officers, juvenile probation supervisors, detention
☐ Dept. of Health personnel whose duties include, or result in, the
superintendents, assistant detention superintendents, juvenile justice
determination/adjudication of eligibility for social security disability
detention officers I/II, juvenile justice detention officer supervisors,
benefits, investigation/ prosecution of complaints filed against health
juvenile justice residential officers, juvenile justice residential officer
care practitioners, or inspection of health care practitioners or health
supervisors I II, juvenile justice counselors, juvenile justice counselor
care facilities licensed by the Dept. of Health. †
supervisors, human services counselor administrators, senior human
☐ Dept. of Financial Services personnel whose duties include the services counselor administrators, rehabilitation therapists, and social
investigation of fraud, theft, workers’ compensation coverage services counselors of the Dept. of Juvenile Justice.
requirements and compliance, other related criminal activities, or state
☐ Law enforcement personnel, including correctional officers and
regulatory requirement violations.
correctional probation officers.
☐ Dept. of Revenue personnel or local government personnel whose
☐ Prosecutor (state attorney, assistant state attorney, statewide
duties include revenue collection and enforcement or child support
prosecutor, assistant statewide prosecutor).
enforcement.
☐ Public defenders and criminal conflict and civil regional counsel
☐ Emergency medical technicians or paramedics certified under
(includes assistant public defenders, assistant criminal conflict and
chapter 401, F.S. †
assistant civil regional counsel).
☐ Firefighter certified in compliance with s. 633.408, F.S.
☐ Member of U.S. Armed Forces, reserve component of U.S. Armed
☐ Guardian ad litem as defined in s. 39.820, F.S. † Forces, or National Guard who served after 9/11/2001. †
☐ Human resource, labor relations, or employee relations director; ☐ U.S. Attorney or Assistant U.S. Attorney, U.S. circuit judge, U.S
assistant director, manager, or assistant manager of any local district judge, or U.S. magistrate judge. †
government agency or water management district whose duties include
☐ Victim* of sexual battery, aggravated child abuse, aggravated
hiring and firing employees, labor contract negotiation, administration,
stalking, harassment, aggravated battery, or domestic violence—
or other personnel-related duties.
Please attach official verification that crime occurred—Exemption
☐ Impaired practitioner consultant, retained by an agency, whose for 5 years from date of this request.
duties result in determination of person’s skill and safety to practice
☐ Certified Participant* in Address Confidentiality Program under
licensed profession (includes consultant’s employees). †
s. 741.403, F.S.—Exemption applies only to participant’s name,
☐ Justice of Florida Supreme Court; or judge of district court of address, and telephone number in voter registration and voting
appeal, circuit court, or county court. records—Please attach copy of certification or renewal.
Printed Name: Date of Birth: Phone Number:
Home Address:
Signature (and Title, if app.) of Requester:† Date:
† If specially indicated category selected, person also certifies, by signature herein, that he or she has made reasonable efforts to
protect information from being publicly accessible through other means available to the public.
Form DOS-119 Rev. 4/16
 ADDENDUM FOR EXEMPTION OF PUBLIC DISCLOSURE
ONLY FOR DIVISION OF CORPORATIONS RECORDS

Before the Florida Department of State, Division of Corporations can act on your request; it needs
the following additional information from you:

1. Complete home address that is to be redacted:

2. Are you now or have you ever been listed on the Division of Corporations’ records as:

a. an officer or director of a corporation? Yes No

b. a managing member or manager of a limited liability company? Yes No
c. a general partner in a limited partnership? Yes No
d. an owner of a fictitious name? Yes No
e. a partner in a general partnership? Yes No
f. a notary? Yes No
g. an owner of a trademark registration Yes No

3. Have you ever had a judgment lien filed against you that would have been filed in this office
after October 1, 2001 Yes No

If you answered “Yes” to one or more of the questions, we ask you provide the name of the entity,
registration or filing and an alternate address that can replace the one we currently have in our records.
We cannot have a record with a missing address.

Name/Names of entity or registration:

Alternate address to replace the one current on our records:

Please return this addendum with the Public Records Exemption Request form.
For question concerning this addendum, call 850.245.6862.