Sworn Statement Form – Fill Out and Use This PDF

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) Fla. Stats. (2003). Obtaining confidential information by someone who knows they are not entitled to do so is a felony violation.

The undersigned requests 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 a 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 ____________, 200__, 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

Drivers license or other photographic identification, proof of status or identification that demonstrates qualifications to access this information were reviewed by

_________________________________________________, agency employee, on this ____

day of __________, 200__.

HSMV-94010 (Rev. 08/05)