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 of Requestor: ___________________________________ *Notarized signature is required here for mailing, or form may be brought in personally and notarized in our office. State of ___________ County of _____________ I HEREBY CERTIFY on this day, before me, an officer duly authorized to administer oaths and take acknowledgements, personally appeared, ______________, known to me to be the person(s) described in and who executed the foregoing instrument, who acknowledged before me that he executed the same, and that an oath was not taken. Said person is personally known to me. Witness my hand and official seal in the County and State aforesaid this _______ day of ________ , ___. ______________________Notary Signature Disclaimer: This request only addresses identified images/documents. Additional requests must be filed for future images/documents processed by the Clerk’s Office. ___________________________________________________________________________________ For Office Use Only: Date Request Received ________________ Date Request Completed ________________ Clerk Processing Request ________________