Request Form For Social Security Number Removal

Request Form for Social Security Number Removal Date: Name of Holder of Social Security Number: Phone Number: (optional) Relationship to Requester: [ ] Self [ ] Attorney, specify [ ] Legal Guardian, specify For Redaction/Removal of Social Security Number from an Official Record Image on a Publicly Available Internet website, please provide: Instrument Number/Book and Page Number/Document Type For Redaction/Removal of Social Security Numbers from Court Records, please specify: Case Number/Document Name/Page Number Signature: For Office Use Only: Date Request Received Date Request Completed Clerk Processing Request