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Embed code for: APD Affidavit of Good Moral Character August 2010
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CONTINUED ON NEXT PAGE APD 1649, PDF 08/2010 Page 1 of 3 AFFIDAVIT OF GOOD MORAL CHARACTER State of Florida County of Before me this day personally appeared who, being duly sworn, says: I am an applicant for employment as a direct service provider or other individual screened pursuant to Chapter 435, Florida Statutes, and Section 393.0655, Florida Statutes, or I am currently employed as a direct service provider with: By signing this form, I swear and affirm that I have not been found guilty of or entered a plea of guilty or nolo contendere (no contest) to, regardless of the adjudication, any of the following charges under the provisions of the Florida Statutes or under any similar statute of another jurisdiction. I attest that I have not been arrested for any of the following offenses and am currently awaiting disposition. I also attest that I have not been adjudicated delinquent for any of the following offenses, regardless of whether the records have been sealed or expunged. I understand that I must acknowledge the existence of any criminal records relating to the following list of offenses. I understand that I am also obligated to notify my employer of any possible disqualifying offenses that may occur while employed in a position subject to background screening under Chapter 435, Florida Statutes. I further understand that the list stated below is subject to change and may include offenses that were not previously included. NOTE: The following list of offenses has been updated August 1, 2010, and includes offenses specifically applicable to direct service providers under Chapter 393, Florida Statutes. Offenses Relating to: Sections: 393.0674 Felony offenses for the release or use of information from juvenile records of the Agency for Persons with Disabilities for any purpose other than screening for employment 393.135 Sexual misconduct with certain developmentally disabled clients or threats and/or coercion relating to reports or testimony of sexual misconduct 394.4593 Sexual misconduct with certain mental Health patients 409.920 Medicaid provider fraud 409.9201 Medicaid fraud 415.111 The filing or disclosure of information from reports of adult abuse, neglect, or exploitation of aged persons or disabled adults 741.30 Criminal acts that constitute domestic violence as defined in section 741.28, Florida Statutes 782.04 Murder 782.07 Manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child 782.071 Vehicular homicide 782.09 Killing of an unborn child by injury to the mother Chapter: 784 Assault, battery, and culpable negligence, if the offense was a felony. Sections: 784.011 Assault, if the victim of offense was a minor 784.03 Battery, if the victim of offense was a minor 787.01 Kidnapping 787.02 False imprisonment 787.025 Luring or enticing a child for an unlawful purpose 787.04(2) Taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings 787.04(3) Carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person 790.115(1) Exhibiting firearms or weapons within 1,000 feet of a school APD 1649, PDF 08/2010 Page 2 of 3 790.115(2)(b) Possessing an electric weapon or device, destructive device, or other weapon on school property 794.011 Sexual battery 794.041 Former offenses for prohibited acts of persons in familial or custodial authority 794.05 Unlawful sexual activity with certain minors Chapter: 796 Prostitution Section: 798.02 Lewd and lascivious behavior Chapter: 800 Lewdness and indecent exposure Section: 806.01 Arson Sections: 810.02 Burglary 810.14 Voyeurism, if the offense is a felony 810.145 Video voyeurism, if the offense is a felony Chapter: 812 Felony offenses for theft and/or robbery and related crimes Sections: 817.034 Fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems 817.234 False and fraudulent insurance claims 817.505 Patient brokering 817.563 Felony offenses for the fraudulent sale of controlled substances 817.568 Criminal use of personal identification information 817.60 Obtaining a credit card through fraudulent means 817.61 Felony offenses for the fraudulent use of credit cards 825.102 Abuse, aggravated abuse, or neglect of an elderly person or disabled adult 825.1025 Lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult 825.103 Felony offenses for the exploitation of an elderly person or disabled adult 826.04 Incest 827.03 Child abuse, aggravated child abuse, or neglect of a child 827.04 Contributing to the delinquency or dependency of a child 827.05 Negligent treatment of children 827.071 Sexual performance by a child 831.01 Forgery 831.02 Uttering forged instruments 831.07 Forging bank bills, checks, drafts, or promissory notes 831.09 Uttering forged bank bills, checks, drafts, or promissory notes 843.01 Resisting arrest with violence 843.025 Depriving a law enforcement, correctional, or correctional probation officer means of protection or communication 843.12 Aiding in an escape 843.13 Aiding in the escape of juvenile inmates in correctional institution Chapter: 847 Obscene literature Section: 874.05(1) Encouraging or recruiting another to join a criminal gang Chapter: 893 Drug abuse prevention and control if the offense was a felony or if any other person involved in the offense was a minor Sections: 916.0175 Sexual misconduct with certain forensic clients and reporting requirements for such sexual misconduct 944.35(3) Inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm 944.40 Escape 944.46 Harboring, concealing, or aiding an escaped prisoner 944.47 Introduction of contraband into a state correctional facility 985.701 Sexual misconduct in juvenile justice programs 985.711 Contraband introduced into detention facilities CONTINUED ON NEXT PAGE APD 1649, PDF 08/2010 Page 3 of 3 ONE OF THE FOLLOWING STATEMENTS MUST BE SIGNED: Under the penalty of perjury, which is a first degree misdemeanor, punishable by a definite term of imprisonment, not exceeding one year and/or a fine not exceeding $1,000 pursuant to ss.837.012, or 775.082, or 775.083, Florida Statutes, I attest that I have read the foregoing, and I am eligible to meet the standards of good character for this caretaker position. This means that I have not been found guilty of or entered a plea of guilty or nolo contendere (no contest) to, regardless of adjudication, any of the offenses listed above or any similar statute of another jurisdiction. I attest that I have not been arrested for any of the above offenses and I am not currently awaiting disposition of any of the above offenses. I also attest that I have not been adjudicated delinquent for any of the above offenses, regardless of whether those records have been sealed or expunged. Signature of Affiant OR To the best of my knowledge and belief, my record may contain one or more of the foregoing disqualifying acts or offenses. Signature of Affiant OR I swear or affirm that I am a licensed physician, licensed nurse, or other professional licensed and regulated by the Department of Health. I will be providing services that are within the scope of my licensed practice, and I am not subject to the screening provisions of section 393.0655, Florida Statutes. Signature of Affiant Sworn to and subscribed before me this ______ day of ___________________, ______ My commission expires NOTARY PUBLIC, STATE OF FLORIDA My signature, as a Notary Public, verifies the affiant’s identification has been validated by 810.02 Burglary 810.14 Voyeurism, if the offense is a felony 810.145 Video voyeurism, if the offense is a felony Chapter: 812 Felony offenses for theft and/or robbery and related crimes Sections: 817.034 Fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems 817.234 False a