Free Form 2.110.4a - 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
ST

Defendant Name

) ) ) ) ) )

CASE No. UTCR 2.110 AFFIDAVIT, REQUEST TO
REDACT PROTECTED PERSONAL INFORMATION FROM DOCUMENT EXISTING IN CASE FILE

IMPORTANT NOTE TO PERSON COMPLETING THIS AFFIDAVIT: Except as specifically ordered by a court, this affidavit and UTCR Form 2.100.4b cannot be used for contact information (addresses, telephone numbers, employer identification, and similar information that can be used to contact someone, see UTCR 2.110). The type of information that can be protected by this form is limited to what is listed in UTCR 2.100.

To the court: By this affidavit under UTCR 2.110, I request that the protected personal information in the form attached to this affidavit be redacted from a document in the case file for the case noted above that the general public can see. The protected personal information I request to be segregated is as follows: A. The following is a general description of the protected personal information (example description: "my social security number" or "father's bank account number"). Do not include specific protected personal information here. 1. B. The following is the legal authority by which I believe this information may be exempt from public inspection (cite to statute, rule, case, etc.). Row numbers correspond to those in column A. Add rows in both columns as necessary. 1.

2.

2.

3.

3.

4.

4.

Page 1 - Form 2.110.4a ­ AFFIDAVIT, REQUEST TO REDACT PROTECTED PERSONAL INFORMATION FROM EXISTING CASE FILE ­ UTCR 2.110 (4)(a) (8-1-05)

UTCR App. Page 9

PERSON MAKING REQUEST MUST COMPLETE ALL THE FOLLOWING AS INDICATED: 1. 2. (Initial to confirm) . The specific protected personal information described above is provided on the attached UTCR 2.100 segregated information sheet. The specific protected personal information is in the document in the case file that the following identifies: a. b. c. d. 3. Case file number where found: Description of document containing the information: Page number (identification) of the page(s) containing the information: . . .

A copy of the object page(s) showing specifically the information to be redacted is attached (required): G Yes G No

I have attached the required fee of $ per page for all of the (number of pages) pages I have requested be redacted for a total amount of $ (total amount of check or money order attached). G Yes G No I (initial one) have OR have not attached a self-addressed, stamped postcard with language required by UTCR 2.110 so that the court can inform me of its response to this request. (Initial to confirm) . I understand that while the protected personal information may be withheld from the general public if this request is granted, it may still be available to some persons and government agencies for purposes described in UTCR 2.100. (Initial to confirm, write "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 (not including the attached UTCR Form 2.100.4b and its attachments) to the persons required by UTCR 2.080.

4. 5.

6.

7.

I hereby declare that the above statement, the attached information sheet, and any attachments to the information sheet are 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: Segregation Date: TRIAL COURT ADMINISTRATOR By granted OR denied (state reason) .

Page 2 - Form 2.110.4a ­ AFFIDAVIT, REQUEST TO REDACT PROTECTED PERSONAL INFORMATION FROM EXISTING CASE FILE ­ UTCR 2.110 (4)(a) (8-1-05)

UTCR App. Page 10