Free Attachment C - Oregon

ATTACHMENT C to CJO 03-074, Adopted UTCR Change IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR LINN COUNTY

P 0 Box 1749 Albany OR 97321 (541) 967-3845
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CASE No. UTCR 2.100 SEGREGATED INFORMATION SHEET

ATTENTION COURT STAFF: Except as your trial court administrator tells you otherwise, this sheet and its attachments are: - to be separated from the attached affidavit, and - NOT to be placed in any court file where they can be seen by the public, and - NOT to be provided to any member of the public to see or copy. PLEASE follow UTCR and Judicial Department instructions for protecting information on this form. Ask your trial court administrator if you have questions.
The requestor MUST complete all of the following information: 1. Requestor information: Name: Address: Telephone number: Other contact information: Relationship to case: 2. Protected personal information that is segregated: Row number used to identify on affidavit General description of the protected personal information (same as on affidavit) Relates to (Person's name)
The following is the specific Protected Personal Information to be segregated (give the specific fact, i.e. social security number, etc., tha t is being protec ted ). This can be a refere nce to an attachm ent. Do not use for contact information (addresses, telephone numbers, employer identification, and similar information that can be used to contac t so m eone) un less specifically ord ered by a court. The type of information that can be protected by this form is limited to what is listed in UTC R 2.100. Add rows as necessary.

3. There are a ttachm ents to this info rm ation s hee t: If so, how many pages

Yes

No

For Office u se:

Form 2.100.4b ­ UTCR 2.100 SEGREGATED INFORMATION SHEET ­ UTCR 2.100(4)(b) ­ page 1 with

pages of attachments.