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Department of Economic Opportunity Subrecipient Enterprise Resource Application (SERA) Security Agreement / Confidentiality Form for Subrecipients All fields MUST be completed for access to be granted. Section A — Requestor's Information First Name: Middle Name: Last Name: Job Title: Phone Number: Fax Number: Email: User Contact Information Daniel Organization Address:1801 City: State: Region: Unit(s): Primary Unit Information Name: Indian River County 27th Street Sobczak Vero Beach Long Range Planner FL Zip: 32960 772-226-1253 County: Indian River County 772-978-1806 dsobczakircgov.com Section B — Level of Access Requested PROGRAM GROUP PROGRAM PROGRAM SPECIFIC READ ONLY FULL ACCESS REASON FOR ACCESS WORKFORCE All Workforce Programs ■ ■ ESS ■ 1 WAP • LIHEAP ■ CSBG ■ CDBG ■ ►1 CDBG /1 Reporting, Request for Funding CDBG — DR (List below) • ■ ■ Section C - Subrecipient Access Approval Security / Confidentiality Agreement 15 Your supervisor has authorized you to have access to sensitive data through the use of the Department of Economic Opportunity (DEO) Information Syst s and related media (i.e. printed reports, system inquiries, etc.). All confidential information, particularly Personally Identifiable information (PII) are subject the protection of federal, state and local laws and are to be protected accordingly. Unauthorized access, use, disclosure, modification, and/or destruction confidential information is a crime under state and federal laws, including, but not limited to The Florida Computer Crimes Act, Chapter B15 Florida Statut (F.S.) and Florida's Unemployment Compensation Law, Chapter 443, F.S. CO .11 Q `I certified that I have read the security/confidentiality state nt • inted above. I :r certify and understand that unauthorized access, use modification' dissemination, aqd/or destruction of confidential informa n may .e punis . • a - rime and/or result in disciplinary action taken against me. I acknowledge that I have received, read and that I under and Ch. • 815 .S. a • :ceived any nec larification rom my supervisor. Requestor's Signature Supery sor's ' ignature Daniel Sobczak 7/18/2019 Jason E. Brown 07/19/2019 Date CFO / Executive Director's Bob Solari 07/23/2019 Signature r a Print/Type Name Date Print/Type Name Print/Type Name Date Section D - DEO Authorization SERA ROLE DEO Program Approval DEO BFM Approval DEO Security Officer's DEO IT: Activated SERA PROFILE Signature Print Name Date Signature Print Name Date Approval Signature Inactivated: Print Name Date Date Date