Form HSMV96020 "Request to Withhold Personal Information" Florida TemplateRoller 2021

HSMV 96020 Rev. 01/17 Please refer to section 119. 071 Florida Statutes for specific information regarding each exemption. Current or former sworn or civilian law enforcement personnel neglect exploitation fraud theft or other criminal activities or neglect collection and enforcement or child support enforcement judges Assistant managers of any local government agency or water management district whose duties include hiring and firing employees labor contract negotiation administration or other personnel-related duties detention superintendents juvenile detention officers senior juvenile detention officers juvenile detention officer supervisors house parents I and II house parent supervisors group treatment leaders group treatment leader supervisors rehabilitation therapists and social service counselors of the Department of Juvenile Justice criminal conflict and assistant regional counsel impaired practitioner consultant under specified circumstances include auditing or investigation of waste fraud abuse theft exploitation or other activities that could lead to criminal prosecution or administrative discipline. PUBLIC OFFICIAL LAW ENFORCEMENT AGENCY PERSONNEL AND OTHERS PURSUANT TO SECTION 119. 071 FLORIDA STATUTES REQUEST TO WITHHOLD PERSONAL INFORMATION This request form and corresponding privacy protection applies to current and former sworn or civilian law enforcement personnel public officials active or former service members active or former after 09/11/2001 and other identified individuals their spouses children or dependents who are eligible as outlined in Section 119. 071 Florida Statutes. Those who are eligible can request that the Department of Highway Safety and Motor Vehicles DHSMV withhold personal information contained in their driver/identification vehicle/vessel records maintained by DHSMV. This privacy protection does not apply to the mailing addresses maintained by DHSMV. Mailing addresses may be released for official business regarding motor vehicle or driver license information* The completion of this form is not mandatory but is made available as a convenience to individuals making this request and to ensure that DHSMV has necessary information to update the appropriate records. Please PRINT the personal information requested below. The information required to complete this form is located on the Florida driver license or identification card of the requester. In all cases the date of birth must match the date of birth on the include eligible family members. We must have a statement of eligibility and documentation that indicates the eligibility. Service members impaired practitioner consultants and employees of impaired practitioner consultants a current or former employee of an agency s office of inspector general or internal audit department who are eligible as outlined by s. 119. 071 F* S* must also provide a written statement stating that reasonable efforts have been made to protect their identification and location information from being accessible through other means available to the public* Please return your request with documentation that indicates your eligibility to Department of Highway Safety and Motor Vehicles DHSMV 2900 Apalachee Parkway Room B239 MS 91 Tallahassee Florida 32399 or email to HSMV-Records flhsmv*gov Personal Information of Individual Submitting Request FIRST NAME MIDDLE NAME LAST NAME STREET ADDRESS CITY STATE ZIP CODE Date of Birth Family Member s Driver License or Identification Card Information spouse/child Note See second page for a list of those who are eligible.