PALM BEACH COUNTY PROPERTY APPRAISER’S OFFICE CONFIDENTIAL RECORD REQUEST AFFIDAVIT BEFORE ME, the undersigned authority, personally appeared ____________________________________________________ who in my presence, upon being duly sworn and deposed, states the following: 1. I am over the age of eighteen (18) and have personal knowledge of the matters contained herein. 2. I own / have homestead beneficial interest in the real property (properties) identified by the following *Property Control Number(s): ________-__________-_________-_________-_________-________-_________ ________-__________-_________-_________-_________-________-_________ I own the *tangible personal account (accounts) identified by the following account number(s): _________________________ _________________________ _________________________ 3. My home address is as follows: Street Address___________________________________________________ Apt/Unit No._________ City ____________________________________ State ___________ Zip Code _________________ 4. I request that my home address appearing in the records of the Property Appraiser’s Office be held in confidence pursuant to Sections 119.071(2)(h)1, 119.071(2)(j)1, 119.071(4)(d)1-6 and 493.6122, Florida Statutes, because I am a I am a (please choose only one of the following six options): Current Former Spouse of a current Spouse of a former Child of current Child of former See Reason Codes on second page and place the letter that best fits your situation in the Reason Code field below Reason Code Badge/Certification/License Number (if applicable) Jurisdiction (if applicable) ___________ __________________________________________ _____________________ ___________ __________________________________________ _____________________ 5. I submit this affidavit to the Property Appraiser’s Office to remove my home address from the property tax rolls. 6. I certify that the above information is true and correct. I am familiar with the nature of an oath and with the penalties provided by Florida for falsely swearing to a document. ____________________________________________________________ Owner’s signature COUNTY OF ______________________________ STATE OF ________________________________ SWORN TO and subscribed before me this ______ day of ________________, 20____, by ___________________________________________________ who (check one) is (___) personally known to me or (___) who produced a _______________________________as identification. (Notary Seal) ____________________________________________________________________ NOTARY PUBLIC’S SIGNATURE Please return this affidavit to the Palm Beach County Property Appraiser’s Office, Attn: Confidential Records, 301 N. Olive Ave., Governmental Center, First Floor – West Palm Beach FL 33401. If you have questions, please call (561) 355-2866. NOTE: If you relocate you must submit another Confidential Record Request Affidavit. PBCPAA rev. 1/2017 WEST COUNTY NORTH COUNTY MID-WESTERN COMMUNITIES SOUTH COUNTY SERVICE CENTER SERVICE CENTER SERVICE CENTER SERVICE CENTER 2976 State Road 15 3188 PGA Blvd., Suite 2301 200 Civic Center Way, Suite 200 14925 Cumberland Dr. Belle Glade, FL 33430 Palm Beach Gardens, FL 33410 Royal Palm Beach, FL 33411 Delray Beach, FL 33446 tel 561.996.4890 tel 561.624.6521 tel 561.784.1220 tel 561.276.1250 fax 561.996.1661 fax 561.624.6565 fax 561.784.1241 fax 561.276.1278 Exemption Services Center Governmental Center – First Floor 301 North Olive Avenue West Palm Beach FL 33401 tel.561.355.2866 fax. 561.355.4416 pbcgov.org/PAPA
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PALM BEACH COUNTY PROPERTY APPRAISER’S OFFICE
CONFIDENTIAL RECORD REQUEST AFFIDAVIT
BEFORE ME, the undersigned authority, personally appeared ____________________________________________________
who in my presence, upon being duly sworn and deposed, states the following:
1. I am over the age of eighteen (18) and have personal knowledge of the matters contained herein.
2. I own / have homestead beneficial interest in the real property (properties) identified by the following *Property Control Number(s):