NOTE TO STAFF: This form may contain confidential information. Please do not disclose its contents without first consulting the District Manager.

PRIVACY NOTICE: Under Florida’s Public Records Law, Chapter 119, Florida Statutes, the information you submit on this form may become part of a public record. This means that, if a citizen makes a public records request, we may be required to disclose the information you submit to us. Under certain circumstances, we may only be required to disclose part of the information submitted to us. If you believe that your records may qualify for an exemption under Chapter 119, Florida Statutes, please notify the District Manager and complete the Address/Identification Confidentiality Request from Public Records Disclosure Form.

	RESIDENT INFORMATION	

Last Name 	First Name 	

Street Address 	Lot #	

E-Mail Address 	
I would like to receive e-mails on District programs and events.
PLEASE READ AND SIGN BELOW:
The undersigned agrees and acknowledges that the above information is true and correct The undersigned also acknowledges that any emails sent or received through the Amelia Walk CDD email notification platform may constitute public records under Chapter 190, Florida Statutes, and thus may be subject to disclosure in response to a public records request.

Print Name:		 Signature: 	
Date: 	

On Site Management Initials	

ADDRESS/IDENTIFICATION CONFIDENTIALITY REQUEST FROM PUBLIC RECORDS DISCLOSURE

Florida law allows certain persons to request that a governmental entity not publicly disclose his/her specific identifying information and/or address in any of the entity’s governmental records. If eligible under Florida law, submit this completed form to Amelia Walk Community Development District. Note that this form is not intended to be an exhaustive list of exemptions, and other exemptions may apply. It is your responsibility to ensure that you are eligible under Florida law for the exemption claimed, and the District reserves the right to pursue any available legal remedies if no exemption exists and the District is harmed as a result.
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 Health personnel whose duties are to support the investigation of child abuse or neglect. *
Dept. of Revenue personnel or local government personnel with duties relating to revenue collection and enforcement or child support enforcement. *
Dept. of Business and Professional Regulation investigator or inspector (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.”). *
Firefighter certified in compliance with s. 633.408, 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 personnel-related duties. *
Judge or justice of the Florida Supreme Court, district court of appeal, circuit court and county court. *

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 or supervisor, detention superintendent, assistant detention superintendent, juvenile detention officer I or II, juvenile detention officer supervisor, juvenile residential officer, or supervisors I or II, juvenile counselor or supervisor, human services counselor administrators, senior human services counselor administrators’ rehabilitation therapist, and social services counselor of the Dept. of Juvenile Justice. *
Law enforcement personnel including correctional officers and correctional probation officers. *
Prosecutor (includes 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.”). *
Victimof sexual battery, aggravated child abuse, aggravated stalking, harassment, aggravated battery or domestic violence. (Attach official verification that crime occurred.). This is only a 5-year exemption. **

County Tax Collector (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):	

ADDRESS/IDENTIFICATION CONFIDENTIALITY REQUEST FROM PUBLIC RECORDS DISCLOSURE

Print Name: 	

Residence Address (City, State, Zip): 	_

Prior/Current Position (for purpose of claiming exemption): 	

Years Held: 	

Description of Position: 	

Signature	 Date 	

If request is submitted instead by the person’s employing agency, complete the following:

Agency: 	

Name/Title: 	

Signature: 	Date