Sheriff Eric Flowers
Indian River County

SWORN STATEMENT FOR TRAFFIC CRASH REPORT INFORMATION

Motor vehicle crash information is confidential and exempt from disclosure for a period of 60 days after the date the crash report is filed. §316.066(3)(c), F.S.. Obtaining confidential information by someone who knows they are not entitled to do so is a felony violation.

The undersigned request the following crash report (date/location/parties):

 	_

The undersigned states that he/she or the organization they represent qualify for immediate disclosure of the crash report according to the exemption checked below and does swear or affirm that information contained in a crash report made confidential by statute will not be used for any commercial solicitation of accident victims, or knowingly disclosed to any third party for the purpose of such solicitation, during the period of time that the information remains confidential.

I am a party involved in the crash.
	I am a legal representative to a party involved in the crash:  Fla. Bar No  	 OR Immediate Relative (relation)  	
OR Written Authority from immediate relative, copy attached.
	I am a licensed insurance agent to a party involved in the crash, their insurer or insurers to which they applied for insurance coverage, Fla. License No. 	_
I am a person under contract to provide claims  or  underwriting  information  to  a  qualifying  insurance  company,  identified as:  	
I am a prosecuting authority, Fla. Bar No. 	_
I represent the following radio or television station licensed by the FCC or newspaper qualified to publish legal notices or a free newspaper of general circulation, which qualifies under the statute:
 	_ Name of radio/Television Station, Newspaper
I represent a local, state or federal agency that is authorized by law to have access to these reports
I represent a Victim Service Program, as defined in §316 003(84), Florida Statutes. Name of Program :  	

 	_
Printed Name	Agency/Business Represented

 	_
Signature	Address

(Area Code) Telephone Number	City, State, Zip Code

State of Florida, County of 	
Sworn to (or affirmed) and subscribed before me this day 	of 	201    , by Personally known 	or Produced Identification  	 Type of I.D. produced: 	

Print, Type, or Stamp, Commissioned name of Notary	Signature of Notary Public or Certified Law Enforcement or
Correctional Officer.

4055 41st Avenue, Vero Beach, Florida 32960	www.ircsheriff.org (772) 569-6700