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Department of Economic Opportunity <br />All fields MUST be <br />Subrecipient Enterprise Resource Application (SERA) <br />Security Agreement / Confidentiality Form for Subrecipients <br />completed for <br />access to be <br />granted. <br />Section A — Requestor's Information <br />User Contact Information <br />First Name: Roland <br />Primary Unit Information <br />Organization Name: Indian River County <br />Middle Name: <br />Address:1801 27'h Street <br />Last Name: DeBlois <br />City: Vero Beach <br />Job Title: Interim Community Development Director <br />State: FL Zip: 32960 <br />Phone Number: 772-226-1253 <br />Region: County: Indian River County <br />Fax Number: 772-978-1806 <br />Unit(s): <br />Email: rdeblois@ircgov.com <br />Section B — Level of Access Requested <br />PROGRAM <br />GROUP <br />PROGRAM <br />PROGRAM <br />SPECIFIC <br />READ <br />ONLY <br />FULL <br />ACCESS <br />REASON FOR ACCESS <br />WORKFORCE <br />All Workforce Programs <br />■ <br />■ <br />ESS <br />■ <br />■ <br />WAP <br />• <br />LIHEAP <br />■ <br />CSBG <br />• <br />CDBG <br />■ <br />CDBG <br />►i <br />Reporting, Request for Funding <br />CDBG — DR (List below) <br />• <br />■ <br />■ <br />Section C — Subrecipient Access Approval ... <br />Security / Confidentiality Agreement a� <br />m o <br />Your supervisor has authorized you to have access to sensitive data through the use of the Department of Economic Opportunity (DEO) Information Syjeliss <br />and related media (i.e. printed reports, system inquiries, etc.). All confidential information, particularly.Pe.sonally Identifiable information (PII) are subject <br />the protection of federal, state and local laws and are to be protected accordingly. Unauthorized De,,disclosure, modification, and/or destructim <br />confidential information is a crime under state and federal laws, including, but not limited to Tl li, ' a-Cont*etce7crimes Act, Chapter B15 Florida Staitrn <br />(F.S.) and Florida's Unemployment Compensation Law, Chapter 443, F.S.• :OJT. ' ✓F°• U) •p <br />• s , • <br />m <br />"1 certified that I have read the security/confidentiality statement printed abo . I f rther cPrytif, a •. ers hat unkuthorized access, use modifica Ore <br />dissemination, and/or destruction of confidential informa ' ay be punish a crinle"apd/or r '. , iplin0i� ?ction taken against me. I co <br />acknowledge that I have recei ed, read and that I under and C';: pter 81 ar 1,ve jeceived an a larific3tion from my supervisor. 0 ' <br />- <br />r-Kikil .,-', <br />_ <br />:;' <br />Requestor's Signature Supe isor's' ignature !� '. { 'i FQ- xecutive Director's Signature vN, <br />U <br />Roland DeBlois Jas.n E. zrown ;'FR COU1 •pb Solari Q <br />/ <br />q Prin a Name Date <br />(/ - • Print/Type Name Date 7 / 9 / 19 <br />Print/Type Name Date Wil / <br />Section D — DEO Authorization <br />SERA ROLE SERA PROFILE <br />DEO Program Approval <br />Signature Print Name Date <br />DEO BFM Approval <br />Signature Print Name Date <br />DEO Security Officer's Approval <br />Signature Print Name Date <br />DEO IT: Activated Inactivated: <br />Date Date <br />