DOEA Form 235 "Affidavit of Compliance - Employer" - Florida

Form 235 is a Florida Department of Elder Affairs form also known as the "Affidavit Of Compliance - Employer". The latest edition of the form was released in September 21, 2017 and is available for digital filing.

Download an up-to-date Form 235 in PDF-format down below or look it up on the Florida Department of Elder Affairs Forms website.

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Download DOEA Form 235 "Affidavit of Compliance - Employer" - Florida

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BACKGROUND SCREENING
Affidavit of Compliance - Employer
AUTHORITY: This form is required annually of all employers to comply with the attestation
requirements set forth in section 435.05(3), Florida Statutes.
➢ The term “employer” means any person or entity required by law to conduct background screening,
including but not limited to, Area Agencies on Aging/Aging (and Disability) Resource Centers, Lead Agencies,
and Service Providers that contract directly or indirectly with the Department of Elder Affairs (DOEA), and
any other person or entity which hires employees or has volunteers in service who meet the definition
of a direct service provider. See §§ 435.02, 430.0402, Fla. Stat.
➢ A direct service provider is “a person 18 years of age or older who, pursuant to a program to provide
services to the elderly, has direct, face‐to‐face contact with a client while providing services to the client
and has access to the client’s living area, funds, personal property, or personal identification information
as defined in s. 817.568. The term includes coordinators, managers, and supervisors of residential facilities;
and volunteers.” § 430.0402(1)(b), Fla. Stat.
ATTESTATION:
As the duly authorized representative of
Employer Name
located at
,
Street Address
City
State
ZIP code
I,
do hereby affirm under penalty of perjury
Name of Representative
that the above named employer is in compliance with the provisions of Chapter 435 and section
430.0402, Florida Statutes, regarding level 2 background screening.
Signature of Representative
Date
STATE OF FLORIDA, COUNTY OF
Sworn to (or affirmed) and subscribed before me this
day of
, 20
, by
(Name of Representative) who is personally known
to me or produced
as proof of identification.
Notary Public
Print, Type, or Stamp Commissioned Name of Notary Public
DOEA Form 235, Affidavit of Compliance ‐ Employer, Effective September 21, 2017
Section 435.05(3), F.S.
Form available at:
http://elderaffairs.state.fl.us/english/backgroundscreening.php
BACKGROUND SCREENING
Affidavit of Compliance - Employer
AUTHORITY: This form is required annually of all employers to comply with the attestation
requirements set forth in section 435.05(3), Florida Statutes.
➢ The term “employer” means any person or entity required by law to conduct background screening,
including but not limited to, Area Agencies on Aging/Aging (and Disability) Resource Centers, Lead Agencies,
and Service Providers that contract directly or indirectly with the Department of Elder Affairs (DOEA), and
any other person or entity which hires employees or has volunteers in service who meet the definition
of a direct service provider. See §§ 435.02, 430.0402, Fla. Stat.
➢ A direct service provider is “a person 18 years of age or older who, pursuant to a program to provide
services to the elderly, has direct, face‐to‐face contact with a client while providing services to the client
and has access to the client’s living area, funds, personal property, or personal identification information
as defined in s. 817.568. The term includes coordinators, managers, and supervisors of residential facilities;
and volunteers.” § 430.0402(1)(b), Fla. Stat.
ATTESTATION:
As the duly authorized representative of
Employer Name
located at
,
Street Address
City
State
ZIP code
I,
do hereby affirm under penalty of perjury
Name of Representative
that the above named employer is in compliance with the provisions of Chapter 435 and section
430.0402, Florida Statutes, regarding level 2 background screening.
Signature of Representative
Date
STATE OF FLORIDA, COUNTY OF
Sworn to (or affirmed) and subscribed before me this
day of
, 20
, by
(Name of Representative) who is personally known
to me or produced
as proof of identification.
Notary Public
Print, Type, or Stamp Commissioned Name of Notary Public
DOEA Form 235, Affidavit of Compliance ‐ Employer, Effective September 21, 2017
Section 435.05(3), F.S.
Form available at:
http://elderaffairs.state.fl.us/english/backgroundscreening.php
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