Request for Exemption from PR The City of
Boynton Beach Revised 12/201
City of Boynton Beach
3301 Quantum Blvd.
Boynton Beach,Florida 33426
Phone: (561)742-6275 ( Fax: (561)742-6274
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mRequest for ExemptionRecords
In accordance with Section 119.071,Florida Statutes,certain records of employees,their spouses,and their children,are exempt from
disclosure of public records,if so requested.To ensure that records that are exempt from disclosure are properly identified,please follow
the steps outlined in this document.
STEP 1.Review the Categories listed below.If applicable,check the category(s)that apply:
❑Active or former sworn or civilian law enforcement personnel,including correctional and correctional probation officers,personnel of
the Department of Children and Families whose duties include the investigation of abuse,neglect,exploitation,fraud,theft,or other
criminal activities,personnel of the Department of Healthwhose duties are to support the investigation of child abuse or neglect,and
personnel of the Department of Revenue or local goverrunents whose responsibilities include revenue collection and enforcement or
child support enforcement.
❑Firefighters certified in compliance with s.633.408.
❑Current or former justices of the Supreme Court,district court of appeal judges,circuit court judges,and county court judges.
❑Current or former state attorneys,assistant state attorneys,statewide prosecutors,or assistant statewide prosecutors.
❑General magistrates, special magistrates,judges of compensation claims,administrative law judges of the Division of Administrative
Hearings,and child support enforcement hearing officers.
❑Current or former human resource,labor relations,or employee relations directors,assistant directors,managers,or assistant managers
of any local government agency or water management district whose duties include hiring and firing employees,labor contract
negotiation,administration,or other perso el-related duties.
❑Current or former code enforcement officers.
❑Current or former guardians ad litem,as defined in s. 39.820.
❑Current or former juvenile probation officers,juvenile probation supervisors,detention superintendents,assistant detention
superintendents,juvenile justice detention officers I and II,juvenile justice detention officer supervisors,juvenile justice residential
officers,juvenile justice residential officer supervisors I and II,juvenile justice counselors,juvenile justice counselor supervisors,
human services counselor administrators,senior human services counselor administrators,rehabilitation therapists,and social services
counselors of the Department of Juvenile Justice.
❑Current or former public defenders,assistant public defenders,criminal co ict and civil regional counsel,and assistant criminal
conflict and civil regional counsel.
❑Current or former investigators or inspectors of the Department of Business and Professional Regulation.
❑County tax collectors.
❑Serviceeer(cur-rent or former member of the Armed Forced of the United States,a reserve component of the Armed Forces of the
United States,or the National Guard,who served after September 11,2011).
STEP H.Provide the names(s)of your spouseand/or children and the reason they should be exempt(see categories above).
My spouseand/or dependent child named below belong in the category(s)that I have checked above.I understand that it is my
responsibility to inform the Human Resources and Risk Management Department iediately,should there be a change in e
status of my spouse and/or dependent child listed or not listed below.
(1)Name of spouse or child (1)Indicate category listed above (4)Name of spouse or child (4)Indicate category listed above
(2)Name of spouse or child (2)Indicate category listed above (5)Name of spouse or child (5)Indicate category listed above
(3)Name of spouse or child (3)Indicate category listed above (6)Name of spouse or child (6)Indicate category listed above
STEP M.Print your name, dgn,and date the form.
Employee Printed Name Employee# Signature Date
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