STATE OF FLORIDA LEE COUNTY PROPERTY APPRAISER

STATE OF FLORIDA

LEE COUNTY PROPERTY APPRAISER

MATTHEW H. CALDWELL

Mailing Address: P.O. Box 1546

Fort Myers, Florida 33902-1546

Telephone: (239) 533-6100

Physical Address: 2480 Thompson Street Fort Myers, Florida 33901-3074

Website:

REQUEST FOR EXEMPTION FROM PUBLIC DISCLOSURE

This form must be notarized. Submit completed form in person, by mail, email to publicdisclosure@, or fax to (239) 533-6038. Please attach a copy of your state-issued driver license, or ID card, and provide applicable documentation to verify your eligibility. If you need assistance with this form, please call (239) 533-6100.

Currently, one or more of the properties I own qualify for exemption from public disclosure under ?119, Florida Statutes. With this form, I hereby request exemption from public disclosure including removing my information from the Lee County Property Appraiser's website.

This request applies to the following property(ies):

FolioId / Parcel Number / Account Number: ____________________________________________________

Property Site Address:______________________________________________________________________

Title is held in the following name(s): _________________________________________________________

Please include my additional properties listed on p.2. This request is based on the following:

Court order (Please attach court documents). Current/former employment status of: Myself My spouse My parent (Please attach a copy of the

employee's photo ID and badge, or other proof of employment, e.g., paystub, letter from employer, etc.). Job Title: ____________________________ Office of Employment:_____________________________

U.S. attorneys, assistant U.S. attorneys, judges of the U.S. Courts of Appeal, U.S. district judges, and U.S. magistrates must sign the following statement: I hereby state that I have made reasonable efforts to protect this information from being accessible through other means available to the public.

Signature:_________________________________________________ Date: __________________________

All applicants: I affirm that the above information is true and correct. I understand this form prevents my property information from being disclosed to the public and will block my information from the Lee County Property Appraiser's website. I understand that my information may be shared with the Florida Department of Revenue, the Lee County Tax Collector, and other authorized government agencies, per ?195.084, Florida Statutes.

Signature:_________________________________________________ Date:__________________________ Phone No:________________________________ Email Address:___________________________________

The foregoing was acknowledged before me this ________ day of ___________________________, 20______,

by: __________________________________________ Personally known Produced Identification

Printed name of Property Owner

Type of Identification: _______________________

__________________________________________ Signature of Notary

Please provide a copy of this form to the Lee County Tax Collector as I hereby request that my information also be blocked on their website.

__________________________________________ Printed Name or Stamp of Notary Public (NOTARY SEAL)

___________________________________________________________________________________________________________________

IAAO CEAA Jurisdiction, 2008, 2015 & 2022 --- 2014 IAAO International Award --- 1999 Belon Award 1997 IAAO Most Distinguished Assessment Jurisdiction Award --- 1994 NACO Achievement Award --- 1989 IAAO Public Information Award

REQUEST FOR EXEMPTION FROM PUBLIC DISCLOSURE

FolioId / Parcel Number / Account Number: ______________________________________________________ Property Site Address: _______________________________________________________________________ Title is held in the following name(s): ___________________________________________________________

FolioId / Parcel Number / Account Number: ______________________________________________________ Property Site Address: _______________________________________________________________________ Title is held in the following name(s): ___________________________________________________________

FolioId / Parcel Number / Account Number: ______________________________________________________ Property Site Address: _______________________________________________________________________ Title is held in the following name(s): ___________________________________________________________

FolioId / Parcel Number / Account Number: ______________________________________________________ Property Site Address: _______________________________________________________________________ Title is held in the following name(s): ___________________________________________________________

FolioId / Parcel Number / Account Number: ______________________________________________________ Property Site Address: _______________________________________________________________________ Title is held in the following name(s): ___________________________________________________________

FolioId / Parcel Number / Account Number: ______________________________________________________ Property Site Address: _______________________________________________________________________ Title is held in the following name(s): ___________________________________________________________

FolioId / Parcel Number / Account Number: ______________________________________________________ Property Site Address: _______________________________________________________________________ Title is held in the following name(s): ___________________________________________________________

FolioId / Parcel Number / Account Number: ______________________________________________________ Property Site Address: _______________________________________________________________________ Title is held in the following name(s): ___________________________________________________________

FolioId / Parcel Number / Account Number: ______________________________________________________ Property Site Address: _______________________________________________________________________ Title is held in the following name(s): ___________________________________________________________

FolioId / Parcel Number / Account Number: ______________________________________________________ Property Site Address: _______________________________________________________________________ Title is held in the following name(s): ___________________________________________________________

FolioId / Parcel Number / Account Number: ______________________________________________________ Property Site Address: _______________________________________________________________________ Title is held in the following name(s): ___________________________________________________________

FolioId / Parcel Number / Account Number: ______________________________________________________ Property Site Address: _______________________________________________________________________ Title is held in the following name(s): ___________________________________________________________

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___________________________________________________________________________________________________________________

IAAO CEAA Jurisdiction, 2008, 2015 & 2022 --- 2014 IAAO International Award --- 1999 Belon Award 1997 IAAO Most Distinguished Assessment Jurisdiction Award --- 1994 NACO Achievement Award --- 1989 IAAO Public Information Award

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