highlands county clerk of courts le “luke” brooker request form for

HIGHLANDS COUNTY
CLERK OF COURTS
L. E. “LUKE” BROOKER
REQUEST FORM FOR OFFICIAL RECORDS REMOVAL
(Pursuant to CS/HB 1673 under SB 24-E)
(MILITARY DISCHARGE)
Date: ___________________
Name of Veteran: _____________________________________________
Name of Requestor: ___________________________________________
Relationship to Veteran:
( ) Self
( ) Attorney, specify
( ) Widow, Widower or Personal Representative ( ) Legal Guardian, specify
Requestor’s Form of Identification: _______________________________
Address for Notification Purposes Only
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Phone number (optional)_____________________________
Instrument Number/Book and Page Number/Document Type to be removed:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
FAILURE TO PROVIDE COMPLETE AND ACCURATE INFORMATION MAY
RESULT IN AN INABILITY TO PROCESS THIS REQUEST.
DISCLAIMER: Be advised your request is not retrospective; copies of the Public Record may
have been disseminated prior to your request. It is the responsibility of the requestor to notify the
Office of the Clerk of the Circuit Court of any additional documents the requestor desires exempt
status.
____________________________
Requestor’s Signature
For Office Use Only:
Date Request Received
_____________________
Date Request Completed _____________________
Document Removed By _____________________
Recording Form 9/19/02 Rev.