Exempt Documents / Security System Plan Distribution Form
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2STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
050-020-26
STATE HIGHWAY ENGINEER
EXEMPT DOCUMENTS / SECURITY SYSTEM PLAN
02/13
DISTRIBUTION FORM
Page 1 of 2
Exempt Documents being requested or received are included in those exempt from public disclosure as provided by Section 119.071(3)(b), Florida
Statutes (Attached). Security System Plans being requested are confidential and exempt as provided by Section 119.071(3)(a), Florida Statutes
(Attached). The Exempt Documents relate to work being performed for or required by the Florida Department of Transportation, or work related to the
Department's structures. The following information is being provided as a record of this request or receipt, and distribution of the Exempt Documents or
Security System Plans.
Completion of this form and a signature is required before information will be released (* Indicates Required to Obtain Security System Plans):
A. Entity Requesting/Receiving Documents: (Check All That Apply and Provide Full Name of Entity.)
State Agency*:
Federal Agency*:
Governmental:
Architect:
Engineer:
Contractor:
Other:
B. Entity Name:
___________________________________________________________________________
Address:
Phone:
C. Exempt Documents / Security Systems Plans requested or provided: (Be specific on what is requested or to be provided, and include
description, project numbers, FIN, contract numbers, etc.)
D. Reason for Request/Intended Use:
E. RECIPIENT CERTIFICATION: I, personally, and/or as representative of the above entity, fully understand (check the applicable certification block)
the exempt nature of the Exempt Documents I am receiving and agree to maintain the exempt status of this information in accordance with
Florida law.
the confidential and exempt nature of the Security System Plans I am receiving and agree to maintain the confidential and exempt status of
these Security System Plans in accordance with Florida law.
F. Name of person receiving Exempt Documents / Security Plans: (Printed):
Signature:
Date:
Email:
G. Driver license or photo identification number of recipient:
(Recipient must provide verification of employment with the above entity and verify identity with photo ID)
H. FDOT Employee or Other Individual Providing Exempt Documents or Security Plans:
FDOT Office:
Employee Name:
Other Individual Name:
Name and Office Address of Employer:
I. Exempt Documents / Security Systems Plans provided if different than requested: (Be specific on what is provided, and include description,
project numbers, FIN, contract numbers, etc.)
J. Signature of Person Authorizing Distribution:
Date:
Provider’s Signature (if different than person authorizing distribution):
K. Method of delivery:
Pick-up by requestor
other (specify other method of delivery)
Date Provided:
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