Affidavit Of Good Moral Character

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State of Florida

County of ______________________

Before me this day personally appeared _________________________________________ who, being duly
(Applicant’s/Employee’s Name)
sworn, deposes and says:

As an applicant for employment with, an employee of, a volunteer for, or an applicant to volunteer with ________________________________________________, I affirm and attest under penalty of perjury that I meet the moral character requirements for employment, as required by the Florida Statutes and rules, in that:

I have not been arrested with disposition pending or found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to or have been adjudicated delinquent and the record has not been sealed or expunged for, any offense prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction for any of the offenses listed below:

Section 393.135 Section 394.4593 Section 415.111 Section 741.28 Section 777.04 Section 782.04 Section 782.07
Section 782.071 Section 782.09 Chapter 784 Section 784.011 Section 784.03 Section 787.01 Section 787.02 Section 787.025 Section 787.04(2) Section 787.04(3)
Section 790.115(1) Section 790.115(2)(b) Section 794.011 Former Section 794.041 Section 794.05 Chapter 796 Section 798.02 Chapter 800 Section 806.01 Section 810.02 Section 810.14 Section 810.145 Chapter 812 Section 817.563 Section 825.102 Section 825.1025 Section 825.103 Section 826.04 Section 827.03 Section 827.04 Former Section 827.05 Section 827.071

Relating to: sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct sexual misconduct with certain mental health patients and reporting of such sexual misconduct adult abuse, neglect, or exploitation of aged persons or disabled adults or failure to report of such abuse criminal offenses that constitute domestic violence, whether committed in Florida or another jurisdiction attempts, solicitation, and conspiracy to commit an offense listed in this subsection murder manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child vehicular homicide killing an unborn child by injury to the mother assault, battery, and culpable negligence, if the offense was a felony assault, if the victim of offense was a minor battery, if the victim of offense was a minor kidnapping false imprisonment luring or enticing a child taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceeding 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 exhibiting firearms or weapons within 1,000 feet of a school possessing an electric weapon or device, destructive device, or other weapon on school property sexual battery prohibited acts of persons in familial or custodial authority unlawful sexual activity with certain minors prostitution lewd and lascivious behavior lewdness and indecent exposure arson burglary voyeurism, if the offense is a felony video voyeurism, if the offense is a felony theft and/or robbery and related crimes, if a felony offense fraudulent sale of controlled substances, if the offense was a felony abuse, aggravated abuse, or neglect of an elderly person or disabled adult lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult exploitation of disabled adults or elderly persons, if the offense was a felony incest child abuse, aggravated child abuse, or neglect of a child contributing to the delinquency or dependency of a child negligent treatment of children sexual performance by a child

CF 1649, Nov 2020 [65C-45.001, F.A.C.]


Attestation under penalty of perjury is required by s. 435.05, F.S.

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Section 843.01 Section 843.025
Section 843.12 Section 843.13 Chapter 847 Section 874.05(1) Chapter 893
Section 916.1075 Section 944.35(3) Section 944.40 Section 944.46 Section 944.47 Section 985.701 Section 985.711

resisting arrest with violence depriving a law enforcement, correctional, or correctional probation officer means of protection or communication aiding in an escape aiding in the escape of juvenile inmates in correctional institution obscene literature encouraging or recruiting another to join a criminal gang drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor sexual misconduct with certain forensic clients and reporting of such sexual conduct inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm escape harboring, concealing, or aiding an escaped prisoner introduction of contraband into a correctional facility sexual misconduct in juvenile justice programs contraband introduced into detention facilities

THE FOLLOWING APPLIES ONLY TO THOSE APPLICANTS FOR SUBSTANCE USE AND MENTAL HEALTH DISORDER POSITIONS In addition to the Chapter 435, F.S., listed offenses, the following offenses are also applicable for “Mental Health Personnel” screened pursuant to section 394.4572, F.S., “Service Provider Personnel” and “Peer Specialists” screened pursuant to s. 397.407, F.S.; “Recovery Residence Personnel” screened pursuant to s. 397.487, F.S., and any other substance use or mental health disorder professionals seeking certification requiring screening under s. 408.809, F.S.

Chapter 408 Section 408.8065(3)

Section Section Section Section Section Section Section Section Section Section Section Section Section Section Section Section Section

409.920 409.9201 777.04 817.034 817.234 817.481 817.50 817.505 817.568 817.60 817.61 831.01 831.02 831.07 831.09 831.30 831.31

Section 895.03 Section 896.101

Relating to: felony offenses contained in Chapter 408 offers service or skilled service without valid license when licensure is required, or knowingly files a false or misleading license or license renewal application, or submits false or misleading information related to application Medicaid provider fraud Medicaid fraud attempts, solicitation, and conspiracy to commit an offense listed in this subsection fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems false and fraudulent insurance claims obtaining goods by using a false or expired credit card or other credit device, if the offense was a felony fraudulently obtaining goods or services from a health care provider patient brokering criminal use of personal identification information obtaining a credit card through fraudulent means fraudulent use of credit cards, if the offense was a felony forgery uttering forged instruments forging bank bills, checks, drafts or promissory notes uttering forged bank bills, checks, drafts, or promissory notes fraud in obtaining medicinal drugs the sale, manufacture, delivery, or possession with the intent to sell, manufacture, deliver any counterfeit controlled substance, if the offense was a felony racketeering and collection of unlawful debts the Florida Money Laundering Act

I also affirm that I have not been designated as a sexual predator pursuant to s. 775.21, F.S.; a career offender pursuant to s. 775.261, F.S.; or a sexual offender pursuant to s. 943.0435, F.S., unless the requirement to register as a sexual offender has been removed pursuant to s. 943.04354, F.S.

I understand that I must acknowledge the existence of any applicable criminal record relating to the above lists of offenses including those under any similar statute of another jurisdiction, regardless of whether or not those records have been sealed or expunged. Further, I understand that, while employed or volunteering at ________________________________________________ in any position that requires background screening as a condition of employment, I must immediately notify my supervisor/employer of any arrest and any changes in my criminal record involving any of the above listed provisions of Florida Statutes or similar

CF 1649, Nov 2020 [65C-45.001, F.A.C.]


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statutes of another jurisdiction whether a misdemeanor or felony. This notice must be made within one business day of such arrest or charge. Failure to do so could be grounds for termination.
I attest that I have read the above carefully and state that my attestation here is true and correct that my record does not contain any of the above listed offenses. I understand, under penalty of perjury, all employees in such positions of trust or responsibility shall attest to meeting the requirements for qualifying for employment and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses. I also understand that it is my responsibility to obtain clarification on anything contained in this affidavit which I do not understand prior to signing. I am aware that any omissions, falsifications, misstatements or misrepresentations may disqualify me from employment consideration and, if I am hired, may be grounds for termination or denial of an exemption at a later date.
SIGNATURE OF AFFIANT:_______________________________________________________
Sign Above OR Below, DO NOT Sign Both Lines
To the best of my knowledge and belief, my record contains one or more of the applicable disqualifying acts or offenses listed above. I have placed a check mark by the offense(s) contained in my record. (If you have previously been granted an exemption for this disqualifying offense, please attach a copy of the letter granting such exemption.) (Please circle the number which corresponds to the offense(s) contained in your record.)
SIGNATURE OF AFFIANT:_______________________________________________________
Sworn to and subscribed before me this _____ day of ___________, 20___.
___________________________________________________ SIGNATURE OF NOTARY PUBLIC, STATE OF FLORIDA
___________________________________________________ (Print, Type, or Stamp Commissioned Name of Notary Public)
(Check one) Affiant personally known to notary
Affiant produced identification Type of identification produced:______________________________

CF 1649, Nov 2020 [65C-45.001, F.A.C.]

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Affidavit Of Good Moral Character