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___________________________________________________________________________________________________________
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Revised 03/20/2020
TAX DEED SALE- EXCESS PROCEEDS AFFIDAVIT/STATEMENT OF CLAIM
____________________________________________, being the first duly sworn, deposes and says:
(Print/Type Name of Affiant and Title if applicable)
1. That as further stated herein, I am one of the persons described in F.S. 197.502(4). to wit:
____ a. Legal titleholder of record at the time of sale who acquired title to property described below by that conveyance
recorded at OR Book _______ Page _______, in the Official Records of Pinellas County, Florida, and I/we have
held the fee simple title to same continuously up to the time of issuance of the tax deed.
____ b. Lien holder or Mortgagee of record pursuant to that document(s) recorded at:
OR Book ________ Page ________, OR Book ________ Page ________, in the Official Records of Pinellas County, Florida. Affiant is a duly
authorized officer or representative of lienholder or mortgagee. Affiant further states that its lien(s) remaining on DATE OF SALE against the
below-described property totaled $_______________ and such lien(s) have not been transferred, assigned or satisfied.
____ c. Vendee of a recorded contract (recorded at OR Book _______, Page ______) or vendee who has applied to receive notice
____ d. Other lien holder who has applied to receive notice
____ e. Person to whom the property was last assessed on the tax roll for the year in which the property was last assessed
____ f. OTHER:_____________________________________________________________________________________.
Describe how interest was acquired if by other than the above enumerated means (for example, Court Order, Probate, assignment), and
attach appropriate copies of all pertinent documents.
2. Of certain real property legally described as:
3. That, because of delinquent real property taxes, the above described real property was sold under the administration of the
Clerk of Circuit Court of Pinellas County, Florida, on all in accordance with and pursuant to law.
4. 4. That at the aforesaid time of sale of the above described real property, as connected with Tax Certificate #:
Sale of: , I am one of those persons described in paragraph 1 above and entitled under Florida Statutes 197.582 to certain
undistributed surplus funds as my interests appear. My 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). Do you claim this property was your homestead at the time of sale?
____ Yes ____ No.
5. Attached, as required, is a copy of my Notice of Overbid Surplus Monies as well as other documents substantiating my claim and the amount
of such claim, including a ledger or account record verifying the lien amount due as of the date of the tax deed sale and documentation
verifying my authority to make such a claim (if applicable).
6. I request that payment of any surplus funds due me be made payable to:_________________________ and such payment
be mailed to either the address below or to: _____________________________________________________________.
Or (if applicable):
7. Any interest in the surplus funds from the above referenced Tax Deed file is hereby DISCLAIMED because
___________________________________________________________________________________________.
Signature of Affiant:
Affiant Name and Title:
Affiant Address:
Affiant Telephone: Affiant Email:
STATE OF ________________________
COUNTY OF ______________________
The foregoing instrument was acknowledged before me by means of __ physical presence or __ online notarization, this _____day of
__________________, 20 ______ by ______________________, who is personally known to me or has produced __________________________, as
identification and who did/did not take an oath.
Notary Public
My commission expires:
