W/AFFIDAVIT-TDA UNCL-OTHER
PASCO COUNTY CLERK & COMPTROLLER
AFFIDAVIT OF ENTITLEMENT TO UNCLAIMED FUNDS
IN ACCORDANCE WITH LAWS OF FLORIDA, CHAPTER 197
TAX DEED SALE EXCESS PROCEEDS
, who being first duly sworn, deposes and says:
1. That, as further stated in paragraph 3 below, I am one of the persons described in F.S. 197.502(4), to wit:
1. Person to whom the property was assessed on the tax roll for the year in which property was last
assessed.
2. Legal titleholder of record whose address appears on the record of conveyance of the lands to
the owner.
3. Lien holder of record whose address appears on the recorded lien.
4. Mortgagee of record whose address appears on the recorded mortgage.
5. Vendee of a recorded contract or vendee who has applied to receive notice.
6. Other lien holder who has applied to receive notice.
2. That certain real property situated in Pasco County, Florida, to which this claim applies, and legally described
as follows:
Parcel Number:
Physical Address:
3. That, because of delinquent real property taxes, the above described real property was sold under the
administration of the Clerk of the Circuit Court of Pasco County, Florida, on , 20 , all in
accordance with and pursuant to law.
4. That, at the aforesaid time of sale of the above described real property, as connected with Tax Certificate No.
, and Tax Deed Application No. , I am one of those persons described in
paragraph 1 above and entitled under Florida Statutes 197.582(2) to certain undistributed surplus funds as
my interests appear. The maximum entitlement to such funds is $ , which is subject to all
other claims by such other persons, as described in F.S. 197.502(4), within a two year period.
Please consider this formal direction to pay all such funds to the order of:
Name:
Address:
Signature Signature
County of State of
The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online
notarization, this day , 20 , by .
Personally Known or
Produced Identification
Notary Public:
Printed Name:
My Commission expires:
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