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
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