Public Records Exemption Form

Pursuant to 119.071(2)G)(I) /Florida Constitution Article 1,§16(b)

Case Report #:

As a victim of one or more crimes specified in Florida Statute 119.071(2)G)(l)/ Florida Constitution Article 1,§16(b) you may request an exemption PROHIBITING the disclosure of information to the general public which reveals identifiable information. Identifiable information includes but is not limited to your name, your home and work phone numbers, home and work addresses, photos, personal assets, financial records or anything not otherwise held confidential or exempt from the provisions of the Public Records Law; FS 119.071(2)G)(l)/FL CONSTITUTION ARTICLE 1,§16(b).

Do you wish to exercise this right?

(please check one and initial)

Name: YES

Initials

Initials

Signature of Victim Date

Signature of Witness Date