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._________ Phone Number: _____________________
City _______________________________ State _____ Zip Code __________ E-Mail: ________________________________
4. I
request that my property identification and location information appearing in the records of the Property Appraiser’s Office be held in
confidence pursuant to F.S. 119.071and F.S. 493.6122.
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, place the number that best fits your situation in the Reason Code field below
Reason Code Badge/Certification/License Number (if applicable) Jurisdiction (if applicable)
___________ __________________________________________ _____________________
I
f you are the child: Name of Parent: ___________________________________________________
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. 6/2019
WEST COUNTY
SERVICE CENTER
2976 State Road 15
Belle Glade, FL 33430
tel 561.996.4890
fax 561.996.1661
NORTH COUNTY
SERVICE CENTER
3188 PGA Blvd., Suite 2301
Palm Beach Gardens, FL 33410
tel 561.624.6521
fax 561.624.6565
MID-WESTERN COMMUNITIES
SERVICE CENTER
200 Civic Center Way, Suite 200
Royal Palm Beach, FL 33411
tel 561.784.1220
fax 561.784.1241
SOUTH COUNTY
SERVICE CENTER
14925 Cumberland Dr.
Delray Beach, FL 33446
tel 561.276.1250
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/Circumstance (Below are the Occupations/Circumstance currently available for Confidential Status)
Reason Code
1. *^ Sworn or Civilian Law Enforcement Personnel
Requires Badge Number
Requires Jurisdiction
2. *^ Correctional Officers
Requires Badge Number
3. * ^ Department of Children & Family Services whose duties
include the investigation of:
Abuse; Neglect; Exploitation; Fraud; Theft; or other Criminal
Activity
4. *^ Department of Revenue & Local Government Personnel whose
duties include Revenue Collection & Enforcement
5. *^ Firefighters (Pursuant to Florida Statue 633.408)
Requires Certification Number
6. *^ 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
7. *^ 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
8. *^ Department of Health Personnel whose duties include:
Eligibility or adjudication for Social Security Disability benefits
Inspection of health care practitioners or health care facilities
Support & investigation of child abuse or neglect
9. *^ State Attorneys/Assistant State Attorneys:
State Attorney/Assistant State Attorney
Statewide Prosecutors/Assistant Statewide Prosecutors
10. *^ U.S. Attorney/Assistant U.S. Attorney/Judge of U.S. Courts of
appeal/U.S. District Judge/U.S. Magistrate
11. *^ Federal Judges and Magistrates:
General Magistrate
Special Magistrate
Judges of Compensation claim
Administrative Law Judges of the Division of Administrative Hearings
Child Support Enforcement Hearing Officers
12. *^ Code Enforcement Officers
13. *^ Investigative personnel of the Department of Financial Services
14. Private Investigative, Private Security Repossession Services:
Class C, CC, E, or EE Licensees (Must provide copy of License)
15. 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.
Must include official verification that an applicable crime has
occurred.
Reason Code
16. 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.
17. *^Guardian Ad Litem:
18. *^ Public Defender/Assistant Public Defender
Criminal Conflict & Civil Regional Counsel
Assistant Criminal Conflict & Civil Regional Counsel
19. *^ Military 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.
20. *^ Impaired Practitioner Consultants who are:
Retained by an agency
Duties result in a determination of the a person’s skill and safety to
practice a licensed profession
21. *^ 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
22. *^ Office of Inspector General/Internal Audit Department Personnel
Whose duties include auditing or investigating waste, fraud,
abuse, theft, exploitation, or other activities that could lead to
criminal prosecution or administrative discipline.
23. *^ Certified Emergency Medical Technicians/ Certified Paramedics
under Ch. 401
24. *^ Department of Business & Professional Regulations
Investigators/Inspectors
25. Public Guardian
Appointed by a Court and deemed to be an officer of the
Court for an incompetent or incapacitated person.
26. Child Advocacy Personnel/Child Protection Team
Directors, Managers, Supervisors, and Clinical Employees
27. Addiction Treatment Facility Personnel
Directors, Managers, Supervisors, Nurses, and Clinical
Employees
28. Victim of an Incident of Mass Violence
29. Current County Tax Collector
30. *^Office of Financial Regulation’s Bureau of Financial Investigations
* Current or Former Employee
^ Spouse or Child may apply for confidential status