Free Attachment D - Oregon

ATTACHMENT D 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
) ) ) ) ) CASE No. REQUEST TO INSPECT UTCR 2.100 SEGREGATED INFORMATION SHEET

P laintiff N am e

V.
D efendant N am e

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. My Name: My Address: My Telephone number: Other contact information for me:

e. I believe I have a legal right to see the information because (explain reasons):

2. To identify the UTCR 2.100 Segregated Information Sheet (SIS) I am requesting: 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) a. b. c. d.

Form 2.100.8 ­ REQUEST TO INSPECT UTCR 2.100 SEGREGATED INFORMATION SHEET ­ UTCR 2.100(8) ­ page 1

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). (Initial to confirm) I have mailed or delivered copies of this request to the following people required by UTCR 2.080, (List names)

b.

.

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 courts.

I knowingly give the information in this request under an oath or affirmation attesting to the truth of what is stated and subject to sanction by law if I knowingly provide false information to the court. Date OSB# (if applicable) Signature Type or print name

For Office use: Request to inspect Related comments: granted OR denied (state reason)

Date: TRIAL COURT ADMINISTRATOR By

Form 2.100.8 ­ REQUEST TO INSPECT UTCR 2.100 SEGREGATED INFORMATION SHEET ­ UTCR 2.100(8) ­ page 2