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