Segregated Information Sheet
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Segregated Information Sheet Form. This is a Oregon form and can be use in Jackson Local County.
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Tags: Segregated Information Sheet, Oregon Local County, Jackson
DOCUMENT 3B - 3
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 SEGREGATED
INFORMATION SHEET SOCIAL SECURITY NUMBER(S) ONLY
(SHORT FORM)
ATTENTION COURT STAFF: The information set forth below must be segregated
from the applicable court file and may not be shown to any member of the public except by
order of the court.
1. Requestor Information (Contact address and telephone number may be used):
Name_______________________________________________________________
Address_____________________________________________________________
Telephone Number(s)__________________________________________________
Other Contact Information_______________________________________________
□ Petitioner
□ Respondent
2. Segregated Social Security Numbers
Petitioner Name_______________________________ SSN____________________
Respondent Name_____________________________ SSN____________________
Child(ren) of the parties (if applicable)
Name_________________________________ SSN____________________
Name_________________________________ SSN____________________
Name_________________________________ SSN____________________
Name_________________________________ SSN____________________
Name_________________________________ SSN____________________
UTCR 2.100 SEGREGATED INFORMATION SHEET - SOCIAL SECURITY NUMBER(S) ONLY - PAGE 1 OF 1 (11/26/08)
(SHORT FORM) – FORM 2.100.4d
OJIN CODE: IFSI_____
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