Public Records Exemptions

Request Form to Claim Exemption for Inspection or Copying of Public Records
Utilities Commission, City of New Smyrna Beach, Florida
Phone (386) 427-1361 | Fax (386) 424-2713 | www.ucnsb.org
Customer Information
First Name:
Last Name:
Account Number:
Service Address:
E-Mail:
City:
State:
Zip Code:
Phone#:
Daytime:
Name of person in household claiming exemption:
First Name
         Last Name
 
Exemption Claimant Information
Relationship to U.C. Customer:
Self   Spouse   Child   Parent
Please mark all that apply to person claiming exempt status:
Current or Former
juvenile probation officer or supervisor of the Department of Juvenile Justice
juvenile detention officer or supervisor of the Department of Juvenile Justice
house parents I or II or supervisors of the Department of Juvenile Justice
group treatment leaders or supervisors of the Department of Juvenile Justice
rehabilitation therapists of the Department of Juvenile Justice
social services counselors of the Department of Juvenile Justice
law enforcement officer/employee
correctional and correctional probation officer
employee of the Department of Children and Family Services whose duties include the investigation of abuse, neglect, exploitation, fraud, theft, or other criminal activities
employee of the Department of Health whose duties are to support the investigation of child abuse or neglect
employee of the Department of Revenue or local governments whose responsibilities include revenue collection and enforcement or child support enforcement
firefighter certified in compliance with Florida State statute 633.35
justice of the Supreme Court, district court of appeal judge, circuit court judge, and county court judge
current or former state attorney, assistant state attorney, statewide prosecutor, or assistant statewide prosecutor
current or former 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
current or former United States attorney and assistant United States attorney
current or former judge of United States Courts of Appeal, United States district judge, and United States magistrate judge;
current or former code enforcement officer
current or former guardian ad litem, as defined in Florida State Statute 39.820
victim of harassment, aggravated battery, aggravated stalking, aggravated child abuse, domestic violence, sexual battery, with official verification of crime (i.e. police report or court determination)
I verify the information contained in this application is true to the best of my knowledge.
*All fields marked with a red asterisk are required
 
Applicant Signature
By clicking submit I agree to digitally signing this document and agree to any and or all Terms and Conditions that may apply.