"Statement of Authorization and Use of Social Security Account Numbers of Youth Being Served by the Department of Juvenile Justice (DJJ)" - Florida

Statement of Authorization and Use of Social Security Account Numbers of Youth Being Served by the Department of Juvenile Justice (DJJ) is a legal document that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida.

Form Details:

  • Released on August 19, 2009;
  • The latest edition currently provided by the Florida Department of Juvenile Justice;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

ADVERTISEMENT
ADVERTISEMENT

Download "Statement of Authorization and Use of Social Security Account Numbers of Youth Being Served by the Department of Juvenile Justice (DJJ)" - Florida

152 times
Rate (4.4 / 5) 9 votes
FDJJ-1700 –1
New 8/19/09
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Statement of Authorization and Use of Social Security Account
Numbers of Youth being served by the Department of Juvenile Justice
(DJJ)
The Department of Juvenile Justice (DJJ) is authorized under Section 119.071 (5) Florida Statutes
to obtain and use your Social Security Account Number (SSAN) solely for the purpose of positive
identification of youth under its jurisdiction, its staff and the staff of provider agencies under
contract with the Department. Positive identification is imperative for the performance of the
agency’s duties and responsibilities, such as is necessary to determine Medicaid eligibility. Your
Social Security Account Number may be given to the Department’s contracted providers only for
the purpose stated above.
Your SSAN will otherwise remain confidential. The use or sharing your SSAN for any other
purpose is forbidden under Section 119.071 (5) Florida Statutes and DJJ Policy # 1700.
Your signature attests to the fact that you were provided a copy of this statement.
Signed: ______________________________
Date: ______________
The youth was informed of the use of the SSAN but refused to sign.
DJJ staff: ____________________________
Date: ______________
Attachment 1
2737 Centerview Drive
Tallahassee, Florida 32399-3100
(850) 488-1850
l
l
http://www.djj.state.fl.us
The mission of the Department of Juvenile Justice is to increase public safety by reducing juvenile delinquency through effective
prevention, intervention, and treatment services that strengthen families and turn around the lives of troubled youth.
FDJJ-1700 –1
New 8/19/09
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Statement of Authorization and Use of Social Security Account
Numbers of Youth being served by the Department of Juvenile Justice
(DJJ)
The Department of Juvenile Justice (DJJ) is authorized under Section 119.071 (5) Florida Statutes
to obtain and use your Social Security Account Number (SSAN) solely for the purpose of positive
identification of youth under its jurisdiction, its staff and the staff of provider agencies under
contract with the Department. Positive identification is imperative for the performance of the
agency’s duties and responsibilities, such as is necessary to determine Medicaid eligibility. Your
Social Security Account Number may be given to the Department’s contracted providers only for
the purpose stated above.
Your SSAN will otherwise remain confidential. The use or sharing your SSAN for any other
purpose is forbidden under Section 119.071 (5) Florida Statutes and DJJ Policy # 1700.
Your signature attests to the fact that you were provided a copy of this statement.
Signed: ______________________________
Date: ______________
The youth was informed of the use of the SSAN but refused to sign.
DJJ staff: ____________________________
Date: ______________
Attachment 1
2737 Centerview Drive
Tallahassee, Florida 32399-3100
(850) 488-1850
l
l
http://www.djj.state.fl.us
The mission of the Department of Juvenile Justice is to increase public safety by reducing juvenile delinquency through effective
prevention, intervention, and treatment services that strengthen families and turn around the lives of troubled youth.