Affidavit Of Good Moral Character

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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
Page 1 of 3
APD 08/01/2010

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