Free Form 2.100.4b - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR COUNTY Division (court's address and phone number)

Case name:
Plaintiff Name

v.
ST

) ) ) ) ) )

CASE No. UTCR 2.100 SEGREGATED INFORMATION SHEET

1

Defendant Name

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: Protected personal information that is segregated: 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, e.g. social security number, that is being protected). This can be a reference to an attachment. Do not use for contact information (addresses, telephone numbers, employer identification, and similar information that can be used to contact someone) unless specifically ordered by a court. The type of information that can be protected by this form is limited to what is listed in UTCR 2.100. Add rows as necessary.

2.

Row number used to identify on affidavit

3.

There are attachments to this information sheet: If so, how many pages

Yes

No

For Office use:

Form 2.100.4b ­ UTCR 2.100 SEGREGATED INFORMATION SHEET ­ UTCR 2.100(4)(b) ­ page 1 with attachments. (Revised 8-1-05)

pages of

UTCR App. Page 4