Request Form For Social Security or Account Number* Removal per Florida Statute 119.0714(3) *includes complete bank account, debit, charge, or credit card number Date:________________________ Name of Holder of SSN or Account Number: ________________________________________ Phone Number: (optional)_______________________________________________________ Relationship to Requester: [ ] Self [ ] Attorney, specify [ ] Legal Guardian, specify For Redaction/Removal of SSN or Account Number from an Official Record Image on a Publicly Available Internet website, please provide: Instrument Number/Book and Page Number/Document Type Signature: _____________________________________________________ Date Request Received:________________________ Date Request Completed:_______________________ Clerk Processing Request:______________________ This document is used to request the removal/redaction of social security or account numbers on documents that are publicly available on the Clerk's Internet website The request must be legibly written, signed, and delivered in person or by mail, facsimile, or electronic transmission to the Clerk/County Recorder. The request must specify the identification page number that contains the social security or account number. No fee is charged for this service. Please complete and mail or fax form to: Recording Division, Lake County Clerk of Circuit Court, 122 E. Main Street, Post Office Box 7800,Tavares, FL 32778-7800 Revised 10/29/2007 FAX: (352) 253-2616 American LegalNet, Inc. www.FormsWorkFlow.com