Redacted Address Request Form printable pdf download

JOHN E. PETALAS

Lake County Auditor

Lake County Government Center

2293 North Main Street

Crown Point, Indiana 46307

REDACTED ADDRESS REQUEST FORM

I, ___________________________________________, fitting the definition of a “Covered Person” as defined

by IC 36-1-8.5-2, am hereby requesting that my address be restricted from the public property database

website currently being provided by the Lake County Auditor’s office. I have read, understand and agree with

the overall policy. I submit the following document to verify my eligibility as a “Covered Person”:

____________________________________.

“Covered Person” includes: (Please check appropriate category)



___ Judge



___ Law Enforcement



___ Public Official



___ Victim of Domestic Violence

__________________________________ _______________ ______________________________________

First Name

Middle

Last Name

__________________________________________________________________________________________

Parcel Address

City

Zip Code

_________________________ _________________________ ________________________________

Work Phone

Cell Phone

E-Mail Address

__________________________________________________________________________________________

Job Title / Department / Office

Signed: _________________________________________

Date: ______________________

Parcel #: ______ - ______ - ______ - _______ - ______________ - ______

PLEASE NOTE that changes in title and/or ownership for the covered parcel will automatically result in the elimination of the previously

redacted address due to the transfer process currently in place. A new request form MUST be submitted to have the redaction reinstated

on the correct parcel and/or for a change of name. A fee of $10.00 will be charged for these additional requests.

IMPORTANT: Changes in the Redacted Address Policy of the Lake County Auditor may be periodically made without official notice to

existing covered persons. Please review the Auditor’s page of the Lake County website for potential changes.

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OFFICE USE ONLY BELOW THIS LINE

Received by: _____________________________________________

Date: ______________

OFFICE SIGN-OFF VERIFICATION (Open Public Internet Site):

AUDITOR: _______________ Date: __________

TREASURER: _______________ Date: __________

ASSESSOR: _______________ Date: __________

SURVEYOR: _______________ Date: __________

RECORDER: _______________ Date: __________

Redacted Address Request Form

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