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.
NOTE TO STAFF: THIS FORM MAY CONTAIN CONFIDENTIAL INFORMATION. DO NOT DISCLOSE ITS CONTENTS
WITHOUT FIRST CONSULTING THE DISTRICT MANAGER.