Victim'S Request For Confidentiality Form - Florida Page 2
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2VICTIM’S REQUEST FOR CONFIDENTIALITY
DOCUMENTS TO BE COPIED AND MODIFIED FOR CONFIDENTIALITY
As a result of my review of the Official Records and Court Records of Hernando County, I hereby agree that the Hernando County
Clerk’s Office has my permission to modify the Official Records and/or a copy of the Court Records for the following documents in
accordance with the particulars of Sections 119.07(3)(s)(1), 741.403, or 741.465 (the applicable Florida Statute as identified on
page1). I understand that copy(s) of court records(s) will be modified in Court Files only if specifically requested and identified
below.
The documents that pertain to me follow:
OFFICIAL RECORDS (Recording / records contained in the Official Records Book):
Date Recorded
Instrument Number
Book
Page
_____________
__________________
_________
_________
_____________
__________________
_________
_________
_____________
__________________
_________
_________
_____________
__________________
_________
_________
_____________
__________________
_________
_________
COURT RECORDS (Records contained in a court file):
Document Type this
Case Type
Case Number
Exemption applies to
Date Filed
_________
_______________________
_______________________________
______________
_________
_______________________
_______________________________
______________
_________
_______________________
_______________________________
______________
_________
_______________________
_______________________________
______________
_________
_______________________
_______________________________
______________
I hereby agree that it is my responsibility to notify and submit a separate “request for confidentiality” to the Clerk of Court
for any future documents that may be filed in the Hernando County Court Records or Official Records Book. I also agree
and understand that only those records specifically identified above will apply to this “request for confidentiality.”
Signature
___________________________________________________________________________________
Printed Name ___________________________________________________________________________________
Date Signed
___________________________________________________________________________________
January 5, 2006 F:\!Department Share\FORMS\RC\PubRecConf\VICTIM.doc
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