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

Occupation (Below are the Occupations currently available for Confidential Status) Reason Code a. *^ Sworn or Civilian Law Enforcement Personnel

Requires Badge Number

Requires Jurisdiction

b. *^ Correctional Officers

Requires Badge Number

c. Firefighters (Pursuant to Florida Statue 633.35)

Requires Certification Number

d. *^Code Enforcement Officers:

e. *^ Attorneys as follows:

State Attorney/Assistant State Attorney

Statewide Prosecutors/ Assistant Statewide Prosecutors

Public Defender/Assistant Public Defender

Criminal Conflict & Civil Regional Counsel

Assistant Criminal Conflict & Civil Regional Counsel

f. *^ Justices or Judges as follows:

Judges of the U.S. Courts of Appeal or District Courts

United States Magistrate

Supreme Court Justices

District Court of Appeals/Circuit/County Court Judges

g. *^Federal Officials as follows:

U.S. Attorney/Assistant U.S. Attorney

h. *^Guardian Ad Litem:

Must supply written statement that reasonable efforts

have been made to protect such information from being

accessible through other means available to public.

i. *^ Department of Revenue & Local Government

Personnel whose duties include Revenue Collection &

Enforcement

j. *^Child Support Enforcement

k. *^Department of Business & Professional Regulations

Investigators/Inspectors

l. *^ Private Investigative, Private Security & Repossession

Services

License Number (A copy of Licenses must be provided)

m. Current Tax Collector

n. *^ Impaired Practitioner Consultants

o. *^ Service member who served after September 11, 2001

Must supply Official Verification of entry

Must supply written statement that reasonable efforts

have been made to protect such information from being

accessible through other means available to public.

p. *^ Certified Emergency Medical Technicians under Ch. 401

q. *^ Certified Paramedics under Ch. 401

r. * ^ Department of Health Personnel whose duties

include:

Support & investigation of child abuse or neglect

* Current or Former Employee

^ Spouse or Child may apply for confidential status

Reason Code

s. * ^ Department of Children & Family Services whose duties

include the investigation of:

Abuse; Neglect; Exploitation; Fraud; Theft; or other

Criminal Activity

t. *^ Water Management District or Local Government

Personnel as follows:

Director/Assistant Director/Manager/Assistant Manager

And employed in one of the following departments:

Human Resources/Labor Relations/Employee Relations

And whose duties include:

Hiring/Firing/Labor Contract

Negotiation/Administration/Other Personnel Duties

u. * ^ Department of Juvenile Justice Personal as follows:

Juvenile Probation Officers/Supervisors

Detention or Assistant Detention Superintendent

Human Services Counselor or Senior Administrators

Juvenile Justice Detention Officers I/II or Supervisor

Juvenile Justice Residential Officer or Supervisor I & II

Juvenile Justice Counselor or Supervisor

Rehabilitation Therapists/Social Services Counselors

v. Magistrates or Judges as follows:

General or Special Magistrates

Judges of Compensation Claims

Administrative Law Judges of the Division of

Administrative Hearings

Child Support Enforcement Hearing Officers

w. *^ Office of Inspector General/Internal Audit Dept Personnel

Whose duties include auditing or investigating waste,

fraud, abuse, theft, exploitation, or other activities that

could lead to criminal prosecution or administrative

discipline.

x. *^ Department of Financial Services/Office of Inspector

General

Non-sworn investigative personnel whose duties include

the investigation of fraud, theft, worker’s compensation

coverage requirements/compliance and other related

criminal activities.

y. Victim of Domestic Violence, Aggravated Stalking,

Harassment or Aggravated Battery

Must include official verification that an applicable crime

has occurred. Information shall cease to be exempt 5

years after the receipt of the written request.

z. Victim of Sexual Battery, Lewd or Lascivious Offense

Committed upon or in the presence of a person less than

16 years of age, Child Abuse, Victim of any sexual

offense.