Free Form 2.100.8 - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR COUNTY

Division (court's address and phone number)

Case name:
Plaintiff Name

v.
1 Defendant Name
st

) ) ) ) )

CASE No. REQUEST TO INSPECT UTCR 2.100 SEGREGATED INFORMATION SHEET

By this form, I request to see or obtain a copy of part or all of a UTCR 2.100 Segregated Information Sheet (SIS) that is being withheld from the public. I have completed this form to provide the information the court requires of me to make this request. I understand the court will not automatically grant this request but will use applicable law to decide whether I have a right to see or copy the information I request. I understand this request will be a public record whether or not granted. 1. Information about me: a. b. c. d. e. 2. My Name: My Address: My Telephone number: Other contact information for me: I believe I have a legal right to see the information because (explain reasons):

To identify the UTCR 2.100 Segregated Information Sheet (SIS) I am requesting: a. b. c. d. Name of person who submitted affidavit for SIS: Date affidavit submitted: Description of document from which information is segregated: General description(s) of protected personal information I am requesting to see (use same general description as on affidavit in file): e. Row number(s) of description of this information on affidavit: f. Name of person to whom information relates (if known): g. The affidavit for the SIS shows that the SIS includes other information I am not requesting to inspect or copy (check one) Yes OR No. (If Yes, this other information will be redacted)

Page 1 - Form 2.100.8 ­ REQUEST TO INSPECT UTCR 2.100 SEGREGATED INFORMATION SHEET ­ UTCR 2.100(8) (Revised 8-1-05)

UTCR App. Page 7

3.

Confirming additional requirements completed: a. (Initial to confirm, "na" if not applicable) If this document was prepared by someone who is not an attorney, I have attached a completed document preparation certification that applies to both this affidavit and the attached form as required by UTCR 2.010(7). b. (Initial to confirm) I have mailed or delivered copies of this request to the following persons required by UTCR 2.080 (list names): . c. (Initial to confirm) I understand that I will be responsible for any costs resulting from the court responding to this request except those costs for which I have obtained a waiver, and will advance money to cover those costs if requested by the court.

I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury. Date OSB# (if applicable) Signature Type or print name

For Office use: Request to inspect Related comments: Date: TRIAL COURT ADMINISTRATOR By granted OR denied (state reason)

Page 2 - Form 2.100.8 ­ REQUEST TO INSPECT UTCR 2.100 SEGREGATED INFORMATION SHEET ­ UTCR 2.100(8) (Revised 8-1-05)

UTCR App. Page 8