LEE COUNTY PROPERTY APPRAISER

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LEE COUNTY PROPERTY APPRAISER Powered By Docstoc
					                                                STATE OF FLORIDA
                      LEE COUNTY PROPERTY APPRAISER
                                   KENNETH M. WILKINSON, C.F.A.
                             2480 Thompson Street, Fort Myers, Florida 33901-3074




  REQUEST FOR EXEMPTION FROM PUBLIC DISCLOSURE OF PERSONAL INFORMATION
                       Please complete a separate request form for each property.
Pursuant to Florida Statute §119.071(4)(d), I request that my home address, telephone number, social security number,
photograph, places of employment of my spouse and children, name and location of schools/day care centers attended by
my children, be exempt from disclosure on the following public record:

  Parcel ID / STRAP Number:
  Property Site Address:
  Owner of Record:
  Home Address:
  Relationship to property owner if not applicant:
This request for confidentiality is based upon my status as:

PROOF OF CURRENT OR FORMER EMPLOYMENT MUST BE ATTACHED TO THIS DOCUMENT
     (Employee ID Badge, Pay Stub, etc. – NOTE: BUSINESS CARDS ARE NOT ACCEPTED)
   Law Enforcement Personnel; Correctional or Probation Officer
   DCF Services Investigator; DOH – Child Abuse or Neglect Support Personnel
   DOR or Local Government Revenue/Tax Collector or Enforcement Officer
   Certified Firefighter (in compliance with s. 633.35)
   Judge / Magistrate
   Local Government or Water Mgmt. Dist. Human Resource Administrator or Employee Relations Director
   United States or Asst. US Attorney; State or Asst. State Attorney; State or Asst. State Prosecutor
   Federal / State / County / Municipal Code Inspector or Code Enforcement Officer
   Guardian Ad Litem (as defined in s. 39.820)
   Dept. of Juvenile Justice – Officer, House Parent, Treatment Leader, Rehab Therapist, Counselor
   Public Defender; Asst. Public Defender; Regional or Asst. Regional Criminal Conflict or Civil Counsel
   DBPR Investigators / Inspectors
   Court Order – Copy of fully executed documents required

I understand I do not meet the eligibility requirements for public records exemption per Florida Statute §119.071 but
request my personal information be blocked from public view on the Property Appraiser’s website only.

 Courtesy - General Public – Property Appraiser’s website only
 ALL APPLICANTS: PLEASE COMPLETE THE INFORMATION BELOW

Signature:                                                                         Date:
Printed Name:
Telephone: Home:                              Work:                              Cellular:

                *ORIGINALS ONLY – FAX/SCANNED COPIES NOT ACCEPTED*
Please return to: Lee County Property Appraiser
                  Attn: Quality Services – KM
                  Post Office Box 1546
                  Fort Myers, Florida 33902
                  (239) 533-6196

                                Tax Collector (FS Only):                    Keyed by:                  Date:
                                                                                                               Rev: 8-15-2012

				
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posted:9/27/2012
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