Request for Removal of Social Security
Number, Bank Account, Credit, Debit,
or Charge Card Number
GENERAL INFORMATION
Name(s) of holder(s) of social security, bank account, credit, debit or charge card numbers:
P
hone n
umber or e-mail address: (required)
Relationship to requestor:
Self
Attorney (specify):
Legal guardian
(specify):
INFORMATION TO BE REMOVED (check all that apply)
Bank account, credit, debit or charge card number
REDACTION/REMOVAL REQUEST FROM AN OFFICIAL RECORDS IMAGE ON THE
CLERK OF THE CIRCUIT COURT & COMPTROLLER’S PUBLIC WEBSITE*
Book & Page** Document Type
Exact page(s) on which
information appears
REDACTION/REMOVAL REQUEST FROM COURT RECORDS*
Case Number*** Case Name
Docket Entry #
Document Name
Page #
* The Clerk shall only remove information specifically identified in this request.
** Please visit our website at www.mypalmbeachclerk.com, Official Records, to locate your documents.
*** Please visit one of our offices to locate the case file containing this information.
Signature:________________________________________ Date:_________________________________
Please note that we are continually increasing our digital image library to include records from prior years. We ask that
you periodically check the online Official Records listing for documents that may contain private personal information.
OFFICIAL USE ONLY
Date request received by HUB_______________________ Dat
e request received by dept.________________________
Date request completed_____________________________ C
lerk processing request______________________________
Clerk of the Circuit Court & Comptroller, Palm Beach County
205 N. Dixie Hwy, Room 4.2500 • P.O. Box 4177 • West Palm Beach, FL 33402-4177
Phone: 561.355.6214 • Fax: 561.355.2633 • www.mypalmbeachclerk.com
• CCRPRIVACY@mypalmbeachclerk.com
Revised 1/5/21
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