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Department of Economic Opportunity <br />All fields MUST be <br />Subrecipient Enterprise Resource Application (SERA) <br />completed for <br />Security Agreement / Confidentiality Form for Subrecipients <br />access to be <br />granted. <br />Section A — Re uestor's Information <br />User Contact Information <br />Primary Unit Information <br />First Name: Matt <br />Organization Name: Indian River County <br />Middle Name: <br />Address: 1801 27th Street <br />Last Name: KalaD <br />City: Vero Beach <br />Job Title: Long Range Planner <br />State: FL Zip: 32960 <br />Phone Number: 772-226-1243 <br />Region: County: Indian River County <br />Fax Number: 772-978-1806 <br />Unit(s): <br />Email: mkalapCa)ircgov.com <br />Section B — Level of Access Requested <br />PROGRAM <br />PROGRAM <br />PROGRAM <br />READ <br />FULL <br />REASON FOR ACCESS <br />GROUP <br />SPECIFIC <br />ONLY <br />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 />® <br />Reporting, Request for Funding <br />CDBG — DR (List below) <br />❑ <br />Is <br />❑ <br />2 <br />b <br />Section C — Subreci lent Access Approval E <br />Security / Confidentiality Agreement <br />Your supervisor has authorized you to have access to sensitive data through the use of the Department of Economic Opportunity (DEO) Information s <br />and related media (i.e. printed reports, system inquiries, etc.). All confidential information, particularly Personally Identifiable information (PII) are su o <br />the protection of federal, state and local laws and are to be protected accordingly. Unauthorized access, use, disclosure, modification, and/or destru of <br />confidential information is a crime under state and federal laws, including, but not limited to The Florida Computer Crimes Act, Chapter B15 Florida S 4, <br />(F.S.) and Florida's Unemployment Compensation Law, Chapter 443, F.S. <br />t� <br />*I certified that I have read the security/confidentiality statement printAabovher certify and understand that unauthorized access, use modifitleh, <br />dissemination, and/ r destruction of confidential informati becrime and/or result in disciplinary action take t me. I <br />ackgo dge th ve received, read and that I under nd Ch teav eceived any ne clarification f supervisor. <br />/ <br />Requestor's Signatidre Supeisor' Signature C / Executive Di or's Signature <br />Matt Kalap ` Jaso E. rown Susan Adams <br />Print/Type Name Date !/� /Zd 2O Print4,yKe Name Date 1/22/2020 Print/Type Name Date 1/22/ 2020 <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 />