Victim'S Request For Confidentiality Form - Florida

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VICTIM’S REQUEST FOR CONFIDENTIALITY
PLEASE NOTE THAT THE SIGNED ORIGINAL OF THIS FORM MUST BE RECEIVED BY THE CLERK’S OFFICE.
FAXED COPIES CANNOT BE ACCEPTED.
SEND TO:
Don Barbee, Jr.
Clerk of Circuit Court
Hernando County
20 N. Main Street – Room 362
Brooksville, FL 34601
I am filing this request for confidentiality in the Hernando County Clerk’s Office in accordance with Florida Statutes pertaining to
victims of crime. I hereby swear or affirm that the following information is true and correct.
I attest that I am an individual covered under one of the following (check T the applicable Florida Statute):
________ F.S. 119.07(3)(s)(1) & 119.07(3)(f)(1)
Case #__________________
________ F.S. 741.403
Case # ____________
________ F.S. 741.465
Case # ____________
OR
Official Verification that an
applicable crime has occurred.
Please print clearly or use a typewriter to complete the following lines.
My full name is :_________________________________________________________________________________________
Other names that I may have used: __________________________________________________________________________
Home address (including city, state, and zip code): ______________________________________________________________
Social Security Number: ___________________________________________________________________________________
Telephone Number: _______________________________________________________________________________________
The information provided on this request for confidentiality is itself to be kept confidential. The information may only be
used by the Hernando County Clerk’s staff in order to process my request for confidentiality.
I agree to indemnity and hold blameless the Hernando County Clerk of Circuit Court and the Clerk’s staff for actions or
reactions that may be the direct or indirect result of my request for confidentiality. Further I agree to personally identify those
documents of record pertaining to be on the attached page.
I agree that it is my responsibility to notify the Hernando County Property Appraiser (352-754-4190) and Tax Collector (352-754-
4180) of any and all exemptions pertaining to this request for confidentiality.
Signature of Individual:______________________________________________ Date:_________________________________
State of Florida
County of
Sworn to (or affirmed) and subscribed before me this ____ day of _____________________________________, 2013
by ___________________________
Personally known (
) or produced the following identification.
Signature of Notary
Notary Seal
January 5, 2006 F:\!Department Share\FORMS\RC\PubRecConf\VICTIM.doc
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