AFFIDAVIT OF GOOD MORAL CHARACTER - APD

AFFIDAVITOF GOODMORALCHARACTERState of FloridaCounty ofBefore me this day personally appeared who, beingduly sworn, says:I am an applicant for employment as a direct service provider or other individual screenedpursuant to Chapter 435, Florida Statutes, or I am currently employed as a direct serviceprovider with:By signing this form, I swear and affirm that I have not been found guilty of or entered aplea of guilty or nolo contendere (no contest) to, regardless of the adjudication, any ofthe following charges under the provisions of the Florida Statutes or under any similarstatute of another jurisdiction. I attest that I have not been arrested for any of thefollowing offenses and am currently awaiting disposition. I also attest that I have notbeen adjudicated delinquent for any of the following offenses, or if have beenadjudicated for one or more of the following offenses, the record has been sealed orexpunged.I understand that I must acknowledge the existence of any criminal records relating to thefollowing list of offenses. I understand that I am also obligated to notify my employer of anypossible disqualifying offenses that may occur while employed in a position subject tobackground screening under Chapter 435, Florida Statutes. I further understand that the liststated below is subject to change and may include offenses that were not previously included.NOTE: The following list of offenses has been updated July 25, 2013, and includes offensesspecifically applicable to direct service providers for the CDC+ Program.Section 393.135Section 394.4593Chapter 408Section 409.920,Section 409.9201,Section 415.111Section 741.28,Section 741.28Section 782.04Section 782.07Section 782.071Section 782.09Chapter 784Section 784.011Section 784.03Section 787.01Section 787.02Relating to:sexual misconduct with certain developmentally disabled clients and reporting of suchsexual misconductsexual misconduct with certain mental health patients and reporting of such sexualmisconductAny violation of this chapter, if the offense was a felonyMedicaid provider fraud.Medicaid fraud.adult abuse, neglect, or exploitation of aged persons or disabled adults or failure to reportof such abusedomestic violence.criminal offenses that constitute domestic violence, whether committed in Florida oranother jurisdictionmurdermanslaughter, aggravated manslaughter of an elderly person or disabled adult, oraggravated manslaughter of a childvehicular homicidekilling an unborn quick child by injury to the motherassault, battery, and culpable negligence, if the offense was a felonyassault, if the victim of offense was a minorbattery, if the victim of offense was a minorkidnappingfalse imprisonment

Section 787.025Section 787.04(2)Section 787.04(3)Section 790.115(1)Section 790.115(2) (b)Section 794.011Former Section 794.041Section 794.05Chapter 796Section 798.02Chapter 800Section 806.01Section 810.02Section 810.14Section 810.145Chapter 812Section 817.034,Section 817.234,Section 817.505,Section 817.563Section 817.568,Section 817.60,Section 817.61,Section 825.102Section 825.1025Section 825.103Section 826.04Section 827.03Section 827.04Former Section 827.05Section 827.071Section 831.01,Section 831.02,Section 831.07,Section 831.09,Section 831.30,Section 831.31,Section 843.01Section 843.025Section 843.12Section 843.13Chapter 847Section 874.05(1)Chapter 893Section 916.1075Section 944.35(3)Section 944.40Section 944.46Section 944.47Section 985.701Section 985.711luring or enticing a childtaking, enticing, or removing a child beyond the state limits with criminal intent pendingcustody proceedingcarrying a child beyond the state lines with criminal intent to avoid producing a child at acustody hearing or delivering the child to the designated personexhibiting firearms or weapons within 1,000 feet of a schoolpossessing an electric weapon or device, destructive device, or other weapon on schoolpropertysexual batteryprohibited acts of persons in familial or custodial authorityunlawful sexual activity with certain minorsprostitutionlewd and lascivious behaviorlewdness and indecent exposurearsonburglaryvoyeurism, if the offense is a felonyvideo voyeurism, if the offense is a felonytheft and/or robbery and related crimes, if a felony offensefraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photoopticalsystems.false and fraudulent insurance claims.patient brokering.fraudulent sale of controlled substances, if the offense was a felonycriminal use of personal identification information.obtaining a credit card through fraudulent means.fraudulent use of credit cards, if the offense was a felony.abuse, aggravated abuse, or neglect of an elderly person or disabled adultlewd or lascivious offenses committed upon or in the presence of an elderly person ordisabled adultexploitation of disabled adults or elderly persons, if the offense was a felonyincestchild abuse, aggravated child abuse, or neglect of a childcontributing to the delinquency or dependency of a childnegligent treatment of childrensexual performance by a childforgery.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, ordeliver any counterfeit controlled substance, if the offense was a felony.resisting arrest with violencedepriving a law enforcement, correctional, or correctional probation officer means ofprotection or communicationaiding in an escapeaiding in the escape of juvenile inmates in correctional institutionobscene literatureencouraging or recruiting another to join a criminal gangdrug abuse prevention and control only if the offense was a felony or if any other personinvolved in the offense was a minorsexual misconduct with certain forensic clients and reporting of such sexual conductinflicting cruel or inhuman treatment on an inmate resulting in great bodily harmescapeharboring, concealing, or aiding an escaped prisonerintroduction of contraband into a correctional facilitysexual misconduct in juvenile justice programscontraband introduced into detention facilitiesPage 2 of 4

I also affirm that I have not been designated as a sexual predator pursuant to s. 775.21; acareer offender pursuant to s. 775.261; or a sexual offender pursuant to s. 943.0435, unless therequirement to register as a sexual offender has been removed pursuant to s. 943.04354.I understand that I must acknowledge the existence of any applicable criminal record relating tothe 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 mustimmediately notify my supervisor/employer of any arrest and any changes in my criminal recordinvolving any of the above listed provisions of Florida Statutes or similar statutes of anotherjurisdiction whether a misdemeanor or felony. This notice must be made within one businessday 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 correctthat my record does not contain any of the above listed offenses. I understand, underpenalty of perjury, all employees in such positions of trust or responsibility shall attest tomeeting the requirements for qualifying for employment and agreeing to inform the employerimmediately if arrested for any of the disqualifying offenses. I also understand that it is myresponsibility to obtain clarification on anything contained in this affidavit which I do notunderstand prior to signing. I am aware that any omissions, falsifications, misstatements ormisrepresentations may disqualify me from employment consideration and, if I am hired, may begrounds for termination or denial of an exemption at a later date.SIGNATURE OF AFFIANT:_______________________________________________________Sign Above OR Below, DO NOT Sign Both LinesTo the best of my knowledge and belief, my record contains one or more of the applicabledisqualifying acts or offenses listed above. (If you have previously been granted anexemption from disqualification, please attach a copy of the letter granting such exemption.)SIGNATURE OF AFFIANT:_______________________________________________________CONTINUED ON NEXT PAGEPage 3 of 4

I swear or affirm that I am a human resource person who has been fingerprinted or screenedpursuant to chapters 393, 394, 397, 402 and 409 or a teacher or noninstructional personnel whohas been fingerprinted pursuant to chapter 1012 and have not been unemployed for more than90 days and who under the penalty of perjury attest to the completion of such fingerprinting orscreening and to compliance with the provisions of this section and the standards for goodmoral character.Signature of AffiantSworn 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 notaryORAffiant produced identificationType of identification produced:______________________________Page 4 of 4