Law Enforcement Use Only
CAFE ( ) - ____________
RF__________ OBTS __________
Category Level ________________
Seminole County Sheriff’s Office, 100 Bush Blvd, Sanford, FL 32773-6706
FELON REGISTRATION FORM
YOU MUST COMPLETE ALL PAGES OF THIS FORM
Florida State Statute 775.13 states that any person who has been convicted of a felony in any
court of this state and/or whose offense may have been found, pursuant to s. 874.04, to have
been committed for the purpose of benefiting, promoting, or furthering the interests of a criminal
gang, the registrant shall identify himself or herself as such an offender, shall within 48 hours
after establishing temporary or permanent residence in this state, register with the sheriff of said
county, regardless of whether adjudication was withheld.
Likewise, any person who has been convicted of a crime in any federal court or in any court of a
state other than Florida, or of any foreign state or country, which if committed in Florida would
be a felony, shall forthwith within 48 hours after entering any county in this state, register with
the sheriff of said county in the same manner as provided in the above listed paragraph. Failure
of any such convicted felon to comply with Florida State Statute 775.13 shall constitute a
misdemeanor of the second degree, punishable as provided in FSS.775.082 or 775.083.
In addition, Florida State Statute 837.06 states that whoever knowingly makes a false statement
in writing with the intent to mislead a public servant in the performance of his/her official duty
shall be guilty of MAKING A FALSE OFFICIAL STATEMENT, punishable as provided in
775.082 or 775.083. Furthermore, Florida State Statue 837.02 states that whoever knowingly
makes a false statement, which he/she does not believe to be true, under oath in an official
proceeding in regards to any material matter shall be guilty of PERJURY IN OFFICIAL
PROCEEDINGS, which is a felony of the 3rd degree, punishable as provided in FSS. 775.083 or
775.084.
(Revised October 2014)
I, ___________________________________, certify that the information given in the following
questionnaire concerning the listed material is true to the best of my knowledge. I further certify
that I am aware of the following statutes and penalties as provided by FSS 837.02, 837.06, and
775.083 to wit; whoever knowingly makes a false statement in writing with the intent to mislead
any law enforcement officer in the performance of his/her official duty is guilty of a misdemeanor
of the second degree, punishable by a definite term of imprisonment not exceeding sixty days.
I understand that my name, address & charges for which I am registering may be placed on the
Seminole County Sheriff’s Office website & remain posted to public view for one year or until I
complete my sanctions which include probation, parole, community service & community control
(life for sex offenders, sexual predators and career offenders); whichever is later. I understand
the sheriff’s office and/or police department may stop by to conduct residency checks. I
understand that if my records are sealed and/or expunged or my sanctions are terminated early,
it is my responsibility to provide such order(s) from a court of competent jurisdiction or my
probation officer (early termination only) to the Sheriff’s Office Felon Registrar.
I also understand that if I am a convicted Sex Offender or Sexual Predator, I am required, under
the provisions of the Florida Jessica Lundsford Act, to report, in person, to the Sheriff’s Office in
the county where I reside, either twice a year or quarterly to re-register my information,
regardless of whether I am under supervisory control. I further certify that I have read and
understand the Seminole County Ordinance 2005-41, if applicable to me, as a sexual predator
or sexual offender with a victim less than 16 years of age.
If you are a resident of the City of Oviedo or have an Oviedo mailing address, you may be
subject to the jurisdiction of the City of Oviedo’s sexual offender ordinance. Please refer to their
pamphlet for further information.
It is your obligation to ensure that you are in compliance with State law, Seminole County
Ordinance 2005-41, and the City of Oviedo Ordinance.
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ OR HAVE BEEN READ THE
INFORMATION ON THIS FORM.
Under penalty of perjury I declare the information is true and correct.
Registrant: _______________________________________ Reporting Officer: _______________________________________
Print Name: ________________________ Date: _________ Print Name: ______________________________ Date: _________
2
REGISTRATION QUESTIONNAIRE
PRINT CLEARLY and answer each question to the best of your knowledge.
Last Name: ___________________________________________________ Jr., Sr., III ____
First Name: ________________________________________________________________
Middle Name: ______________________________________________________________
Maiden Name: ______________________________________________________________
Also Known As: _____________________________________________________________
Date of Birth: ____/____/____MM/DD/YY
Race: ___________ Gender: ___________
Height (feet/inches): ____Ft. _____In. Weight (lbs.) ______
Hair Color: __________ Eye Color: __________
CORRECTIVE LENSES: _____ Glasses, _____ Contacts, _____ None
SSN: _____- ____- ________
DL/ID Number: _____________________________________________ State: ___________
Expiration Date: ____________
Home Address Information:
Subdivision __________________________ Apartment Complex ______________________
Current Street Address: _______________________________________________________
City: ___________________________________ State: _________ Zip: _________________
Home Phone: (_____) ___________________ Cell Phone: (_____) ____________________
Email address: ______________________________________________________________
Place of Birth: City: _______________________ State: _________ Country: _____________
Current Employer: ___________________________________________________________
Street Address: _____________________________________________________________
City: ___________________________________ State: _________ Zip: _________________
Business Phone: (_____) __________________ Job Description: ______________________
Supervisor: ________________________________________ Start Date: ____/_____/_____
3
Indicate the exact location of any scars, marks, piercings and/or tattoos. Describe what they
are: ______________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Vehicle Year & Make _____________________ Vehicle Type _________________________
Vehicle Color ____________ Vehicle License Number _________________ State _________
Print the following information regarding your parents, significant other, children &
siblings. If any family members are deceased, write DECEASED in Current Street
Address.
Father's Full Name: ____________________________________________________________
Race: _______________ Date of Birth: _____/_____/_____
Current Street Address: _______________________________________________________
City: ___________________________________ State: _________ Zip: _________________
Home Phone: (_____) ___________________ Cell Phone: (_____) ____________________
Employer: ____________________________ Occupation: _____________________________
Business Phone: (_____) ___________________
Mother's Full Name: ______________________ Mother's Maiden Name: _________________
Race: _______________ Date of Birth: _____/_____/_____
Current Street Address: _______________________________________________________
City: ___________________________________ State: _________ Zip: _________________
Home Phone: (_____) ___________________ Cell Phone: (_____) ____________________
Employer: ____________________________ Occupation: _____________________________
Business Phone: (_____) ___________________
If you are married, divorced, separated, or have a significant other such as a friend,
roommate, girlfriend, boyfriend or landlord complete the following section.
Full Name: ______________________________ Relationship: _________________________
Race: _______________ Date of Birth: _____/_____/_____
Current Street Address: _______________________________________________________
City: ___________________________________ State: _________ Zip: _________________
Home Phone: (_____) ___________________ Cell Phone: (_____) ____________________
Employer: ____________________________ Occupation: _____________________________
Business Phone: (_____) ___________________
4
List your children:
Child’s Full Name: _____________________________________________________________
Race: _______________ Date of Birth: _____/_____/_____
Current Street Address: _______________________________________________________
City: ___________________________________ State: _________ Zip: _________________
Home Phone: (_____) ___________________ Cell Phone: (_____) ____________________
Employer: ____________________________ Occupation: _____________________________
Business Phone: (_____) ___________________
Child’s Full Name: _____________________________________________________________
Race: _______________ Date of Birth: _____/_____/_____
Current Street Address: _______________________________________________________
City: ___________________________________ State: _________ Zip: _________________
Home Phone: (_____) ___________________ Cell Phone: (_____) ____________________
Employer: ____________________________ Occupation: _____________________________
Business Phone: (_____) ___________________
List your siblings:
Full Name: _______________________________ Relationship: ________________________
Race: _______________ Date of Birth: _____/_____/_____
Current Street Address: _______________________________________________________
City: ___________________________________ State: _________ Zip: _________________
Home Phone: (_____) ___________________ Cell Phone: (_____) ____________________
Employer: ____________________________ Occupation: _____________________________
Business Phone: (_____) ___________________
Full Name: _______________________________ Relationship: ________________________
Race: _______________ Date of Birth: _____/_____/_____
Current Street Address: _______________________________________________________
City: ___________________________________ State: _________ Zip: _________________
Home Phone: (_____) ___________________ Cell Phone: (_____) ____________________
Employer: ____________________________ Occupation: _____________________________
Business Phone: (_____) ___________________
5
List the following information:
DOC Number: ______________________________
Prior to this offense have you ever been convicted of any felony or attempted felony,
regardless of whether adjudication was withheld? _____ YES _____ NO
Have you been convicted as a sex offender or sexual predator? _____ YES _____ NO
If yes, what was the age of your victim at the time of offense? ___________________
If yes, are you now currently, or do you plan to be, a student or employee at any School,
College or University in the State of Florida? _____ YES _____ NO
Where? ______________________________________________________________
Have you ever been affiliated with a gang, hate group, anti-government organization,
militia or similar group? _____ YES _____ NO
Name of gang/set/group: _________________________________________________
If yes, are you willing to discuss your affiliation to an Investigator? ____ YES ____ NO
Are you on Probation? _____ YES _____ NO
Are you on Community Control? ____ YES ____ NO If yes, how long? ____________
Name of Probation/Community Control Officer: ________________________________
Phone Number (_____) ___________________
Have you ever submitted a DNA or swab samples? _____ YES _____ NO
If yes, at which agency or institution?
___________________________________________ Date: _____________________
Which county did your current offense occur? _______________________________
What charges were you sentenced to? ______________________________________
_____________________________________________________________________
What sentence did you receive in court? _____________________________________
_____________________________________________________________________
Sentencing Date: _____________________________
Release Date Prison/Jail: _______________________
Probation Termination Date: _____________________
END OF FELON REGISTRATION FORM
