Request For Confidentiality

CLERK OF THE CIRCUIT AND COUNTY COURTS 11TH JUDICIAL CIRCUIT MIAMI-DADE COUNTY REQUEST FOR CONFIDENTIALITY This request is being made for confidentiality according to Florida Statutes 119. Print your name and reason you are claiming confidentiality based on the above Florida Statute. I attest that as a I am covered under Florida Statute and hereby request that my (Home Address or Social Security Number) be redacted from Book Page of the Official Records of Miami-Dade County. The information provided on this request for confidentiality is itself to be kept confidential. The information may only be used by the Miami-Dade County Recorder222s staff in order to process my request for confidentiality. I agree to indemnify and hold harmless the Miami-Dade Clerk of Courts for any and all claims proximately resulting from this request. Furthermore, I affirm that the only document(s) being redacted is/are identified by Book and Page above. Signature and Date Print Full Name Address City, State, Zip Telephone State of Florida County of Sworn to (or affirmed) and subscribed before me this day of , by Personally known or produced identification Type of identification produced Signature of Notary Complete form(s) with the appropriate information can be mailed or delivered to the Recorder222s Office, 22 NW 1st St., 1st Floor, Miami, Florida 33128. Incomplete document(s) will not be processed. Accepted by: Date: Print Name: CLK/CT. 284 04/15 Clerk222s web address: www.miami-dadeclerk.com American LegalNet, Inc. www.FormsWorkFlow.com