Michelle Franklin, CFA
PROPERTY APPRAISER • Saint Lucie County
2300 Virginia Avenue, Fort Pierce, Florida 34982-5632
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Completed: _______________Received: _______________
Rev. 12/21
CONFIDENTIALITY REQUEST FORM
Pursuant to Section 119.071 Florida Statutes - General exemptions from inspection or copying of public records, I
request that my Name and Transfer Information which may lead to my dwelling location being revealed, be
protected/exempt from disclosure in the Property Appraiser’s records for the property listed below (complete a
form for each parcel id being requested):
Appl
icant: _________________________________________________Co-Applicant: ____________________________________________________
Pr
operty Address: _______________________________________ Or Parcel Number: ______________________________________________
Ho
me Address (if different): _________________________________________________________________________________________________
I am
the owner of the property: ______ Yes ______ No If No, owner’s name: _______________________________________
I qua
lify for protection as: _______ Individual covered by Section 119.071(2), (4), or (5) _____ Spouse _____ Child
Si
gnature of Applicant: __________________________________________ Phone Number: _____________________ Date: ________________
I hereby verify the above information to be true and correct and that I qualify as personnel as defined in Section
119.071 (4) (d) Florida Statute.
STATE OF FLORIDA
COUNTY OF ST LUCIE
Sw
orn to (or affirmed) and subscribed before me by means of [__] physical presence or [_] online notarization, this ______ day of
__
____________, 20_____, by _______________________________, who is Personally Known _____ OR Produced Identification _____ Type of
Id
entification Produced _______________________.
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_____________________________________ Signature of Notary Public - State of Florida
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_____________________________________ Print, Type, or Stamp Commissioned Name of Notary Public
OR
MAI
L TO: SAINT LUCIE COUNTY PROPERTY APPRAISER FAX TO: 772-462-1058
ATTN: RECORDS MANAGEMENT ATTN: RECORDS MANAGEMENT
2300 VIRGINIA AVENUE, ROOM 107
FORT PIERCE, FL 34982-5632 UPLOAD USING QR CODE OR LINK BELOW:
https://www.paslc.gov/ConfReq
Specify the exemption you qualify for as defined in Section 119.071 (4) (d), Florida Statute:
______________________________________________________________________________________________________________________
(Attach driver license and employee ID or other documentation to support the current or former qualifying exemption)
