Affidavit With Request To Segregate Social Security Number(s) Only
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Affidavit With Request To Segregate Social Security Number(s) Only Form. This is a Oregon form and can be use in Jackson Local County.
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Tags: Affidavit With Request To Segregate Social Security Number(s) Only, Oregon Local County, Jackson
DOCUMENT 3B - 4
IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY
In the Matter of:
□ the Marriage of
□ the Domestic Partnership of
)
)
)
)
______________________________
)
Petitioner,
)
)
vs.
)
)
______________________________
)
Respondent.
)
_________________________________ )
CASE NO.__________________________
UTCR 2.100 AFFIDAVIT WITH
REQUEST TO SEGREGATE
SOCIAL SECURITY NUMBER(S) ONLY
(SHORT FORM)
By this affidavit under UTCR 2.100, and as required by ORS 107.840, I request that the
Social Security Number(s) in the attached Segregated Information Sheet be segregated
(kept separate) from information the general public can view. The Social Security
number(s) I request be segregated is/are as follows:
A. Protected Personal Information
B. Legal Authority
□ Petitioner’s Social Security Number
ORS 107.840
□ Respondent’s Social Security Number
ORS 107.840
□ Child(ren)’s Social Security Number(s)
if applicable
ORS 107.840
I have mailed or delivered copies of this request (not including the attached information
sheet) to the opposing party in this matter.
I knowingly give the information in this affidavit and the attached information sheet 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.
Dated:_________________________
Signed:_________________________________
Name:__________________________________
(Please Print)
Address:________________________________
_________________________________
Phone:__________________________________
UTCR 2.100 AFFIDAVIT/REQUEST TO SEGREGATE SOCIAL SECURITY NUMBER(S) ONLY - PAGE 1 OF 1
(11/26/08)
OJIN CODE: AFSI_____
(SHORT FORM) – FORM 2.100.4c
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