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Affidavit (Long Form) Request To Segregate Protected Personal Information From Concurrently Filed Document Form. This is a Oregon form and can be use in Lincoln Local County.
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Tags: Affidavit (Long Form) Request To Segregate Protected Personal Information From Concurrently Filed Document, Oregon Local County, Lincoln
IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR THE COUNTY OF LINCOLN
In the matter of:
__________________________________
Petitioner
and
__________________________________
Respondent
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CASE No.
UTCR 2.100 AFFIDAVIT (LONG FORM)
REQUEST TO SEGREGATE PROTECTED
PERSONAL INFORMATION FROM
CONCURRENTLY FILED DOCUMENT
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 2.100). 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 2.100, I request that the protected personal information in
the form attached to this affidavit be segregated from information that the general public can see in the case
noted above.
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
“parent’s bank account number.” Do not
include specific protected personal information
here.
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.
1.
2.
2.
3.
3.
UTCR 2.100 AFFIDAVIT (LONG FORM), REQUEST TO SEGREGATE PROTECTED PERSONAL
INFORMATION FROM CONCURRENTLY FILED DOCUMENT - Page 1 of 1
SummDisso-1A: UTCR2.100Long-1A-Ver01.doc (1/08)
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4.
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5.
5.
PERSON MAKING REQUEST MUST COMPLETE ALL THE FOLLOWING AS INDICATED:
1. (Initial to confirm)_____.The specific protected personal information described above is provided on
the attached UTCR 2.100 segregated information sheet.
2.(Initial to confirm)______. I have segregated the information described above from another document
or form that I am submitting at the same time, (describe document or form)
,
to keep the protected information from being available to the general public. I appropriately noted in that other
document the places where information has been provided in the attached information sheet rather than in that
document. (No fee is charged when information is segregated at time of submission.)
3. I (Initial one) _____ have OR _____ have not attached a self-addressed, stamped postcard with
language required by UTCR 2.100 so that the court can inform me of its response to this request.
4. (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 as described in UTCR 2.100.
5. (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).
6. (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 people required by UTCR 2.080.
I knowingly give the information in this affidavit, the attached information sheet, and any attachments to the
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.
Date_________________________
Signature______________________________________________
OSB# (if applicable) ___________
Type or print name ______________________________________
For office use:
Request _____ granted
OR _____ denied (state reason)
.
Date: _________________________
TRIAL COURT ADMINISTRATOR
By_______________________________________
UTCR 2.100 AFFIDAVIT (LONG FORM), REQUEST TO SEGREGATE PROTECTED PERSONAL INFORMATION
FROM CONCURRENTLY FILED DOCUMENT - Page 2 of 2
SummDisso-1A: UTCR2.100Long-1A-Ver01.doc (1/08)
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IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR ________________COUNTY
_________Division – _____________________________________________________
(court’s address and phone number)
In the matter of:
__________________________________
Petitioner
And
__________________________________
Respondent
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CASE No.
UTCR 2.100 (LONG FORM)
SEGREGATED INFORMATION SHEET
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: ______________________________________________________
UTCR 2.100 AFFIDAVIT (LONG FORM), REQUEST TO SEGREGATE PROTECTED PERSONAL INFORMATION
FROM CONCURRENTLY FILED DOCUMENT - Page 3 of 3
SummDisso-1A: UTCR2.100Long-1A-Ver01.doc (1/08)
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2. Protected personal information that is segregated:
Row
number
used to
identify
on
affidavit
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, i.e. social security number,
etc., 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.
3. There are attachments to this information sheet: _____ Yes _____ No
If so, how many pages _____
For office use:
UTCR 2.100 AFFIDAVIT (LONG FORM), REQUEST TO SEGREGATE PROTECTED PERSONAL INFORMATION
FROM CONCURRENTLY FILED DOCUMENT - Page 4 of 4
SummDisso-1A: UTCR2.100Long-1A-Ver01.doc (1/08)
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