1 1 1 N W 1
S T
S T R E E T , S U I T E 7 1 0 • M I A M I , F L O R I D A • 3 3 1 2 8
P H O N E :
3 0 5 - 375 - 4 7 1 2 • F A X :
3 0 5 - 375 - 1912
W E B S I T E :
W W W . M I A M I D A D E . G O V / P A
MIAMI-DADE COUNTY
PROPERTY APPRAISER
PUBLIC RECORDS EXEMPTION REQUEST
Please complete and mail to:
Miami-Dade County Office of the Property Appraiser
111 NW 1st Street, Suite 710 Miami, FL 33128-1984
Or via email to: PAWEBMAI[email protected]
I submit this notarized request to the Office of the Miami-
Dade County Property Appraiser to redact my name, telephone number and home address, as defined in
section 119.071(4)(d)1.a. of the Florida Statutes, from the Property Appraiser’s records pursuant to section
119.071, Florida Statutes.
1. Full Name:
Phone Number: E-mail:
2. My home address is as follows (“home addresses” means the dwelling location at which an individual
resides):
Street Address:
Folio Number:
3. Based on the qualifying reasons on Page 2 of this request, I hereby attest:
☐ I, myself, qualify for an exemption from public record.
☐ I am the spouse of an individual who qualifies for an exemption from public record.
Full Name of qualifying spouse:
Employment information of qualifying spouse:
(Must attach copy of marriage certificate)
☐ I am the child of an individual who qualifies for an exemption from public record.
Full name of qualifying parent:
Employment information of qualifying parent:
(Must attach copy of birth certificate)
I understand this information will not be available as part of the public records of the Property Appraiser’s
Office and this may affect the notification process of certain agencies that rely on the property tax roll as their
source of information. I further understand it is my responsibility to notify the Office of the Property Appraiser
if my status changes, and I no longer qualify for the exemption.
Please attach a copy of proof of current or former employment where applicable, this includes, but is
not limited to, employee ID, business card, or official verification from current or former employer’s
Human Resource Department.
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S T
S T R E E T , S U I T E 7 1 0 • M I A M I , F L O R I D A • 3 3 1 2 8
P H O N E :
3 0 5 - 375 - 4 7 1 2 • F A X :
3 0 5 - 375 - 1912
W E B S I T E :
W W W . M I A M I D A D E . G O V / P A
I hereby request exemption based on the following category for which I qualify (check applicable exemption category):
☐ Victim of sexual battery, aggravated child abuse, aggravated
stalking, harassment, aggravated battery, or domestic violence—
Please attach official verification that crime occurred—Exemption
for 5 years from date of this request.
☐ Current or former public guardians and employees with fiduciary
responsibility.
☐ Employee of any licensed facility who provide direct patient care or
security services.
Current government agency employee in the category checked below:
☐ County Tax Collector.
☐ Judicial or quasi-judicial officer (general/special magistrate, judge
of compensation claims, administrative law judge of the Div. of
Admin. Hearings, and child support enforcement hearing officer).
☐ County attorneys, assistant county attorneys, deputy county
attorneys, city attorneys, assistant city attorneys, and deputy city
attorneys.
☐ Clerk, deputy clerks, and clerks of the circuit court personnel.
☐ Code Enforcement Officer.
☐ Dept. of Business and Prof. Reg. investigators and inspectors.
☐ Dept. of Children and Family Services personnel whose duties
involve investigation of abuse, neglect, exploitation, fraud, theft, or
other criminal activities.
☐ Dept. of Health personnel whose duties support the investigations
of child abuse or neglect.
☐ Dept. of Health personnel whose duties include, or result in, the
determination/adjudication of eligibility for social security
disability benefits, investigation/ prosecution of complaints filed
against health care practitioners, or inspection of health care
practitioners or health care facilities licensed by the Dept. of Health.
☐ Dept. of Financial Services personnel whose duties include the
investigation of fraud, theft, workers’ compensation coverage
requirements and compliance, other related criminal activities, or
state regulatory requirement violations.
☐ Dept. of Revenue personnel or local government personnel whose
duties include revenue collection and enforcement or child support
enforcement.
☐ Emergency medical technicians or paramedics certified under
chapter 401, F.S.
☐ Firefighter certified in compliance with s. 633.408, F.S.
☐ Guardian ad litem as defined in s. 39.820, F.S.
☐ Human resource, labor relations, or employee relations director;
assistant director, manager, or assistant manager of any local
government agency or water management district whose duties
include hiring and firing employees, labor contract negotiation,
administration, or other personnel-related duties.
☐ Impaired practitioner consultant, retained by an agency, whose
duties result in determination of person’s skill and safety to practice
licensed profession (includes consultant’s employees).
☐ Justice of Florida Supreme Court; or judge of district court of
appeal, circuit court, or county court.
☐ Inspector general or internal audit dept. personnel whose duties
include auditing/investigating waste, fraud, abuse, theft, exploitation,
or activities that could lead to criminal prosecution or admin.
discipline.
☐ Juvenile probation officers, juvenile probation supervisors, detention
superintendents, assistant detention superintendents, juvenile justice
detention officers I/II, juvenile justice detention officer supervisors,
juvenile justice residential officers, juvenile justice residential officer
supervisors I II, juvenile justice counselors, juvenile justice counselor
supervisors, human services counselor administrators, senior human
services counselor administrators, rehabilitation therapists, and social
services counselors of the Dept. of Juvenile Justice.
☐ Sworn law enforcement personnel, including civilian personnel
employed by a law enforcement agency, correctional officers and
correctional probation officers.
☐ Prosecutor (state attorney, assistant state attorney, statewide
prosecutor, assistant statewide prosecutor).
☐ Public defenders and criminal conflict and civil regional counsel
(includes assistant public defenders, assistant criminal conflict and
assistant civil regional counsel).
☐ U.S. Attorney or Assistant U.S. Attorney, U.S. circuit judge, U.S
district judge, or U.S. magistrate judge.
☐ Victim of an incident of mass violence
☐ D
irectors, managers, supervisors, nurses, and clinical employees of
an addiction treatment facility personnel.
☐ Staff and domestic violence advocates of domestic violence centers
certified by the Department of Children and Families.
☐ Military personnel.
I hereby swear or affirm, under penalty of perjury, that the information contained in the foregoing request form is true and correct.
SIGNATURE: DATE:
REQUIRED NOTARY ACKNOWLEDGMENT
STATE OF FLORIDA, physical presence online notarization
COUNTY OF
Sworn to (or affirmed) and subscribed before me this day of , 20 , by
who is personally known to me OR produced the
following identification .
(Notary Seal)
Signature of Notary
Current or former government agency employee in the category checked
below:
