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Affidavit With Request To Segregate Social Security Numbers Only Form. This is a Oregon form and can be use in Lincoln Local County.
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Tags: Affidavit With Request To Segregate Social Security Numbers Only, 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 WITH
REQUEST TO SEGREGATE
SOCIAL SECURITY NUMBERS 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 that
the general public can see. The social security numbers that I request be segregated are as follows:
A. Protected Personal Information
□ Petitioner’s Social Security Number
□ Respondent’s Social Security Number
□ Child/ren’s Social Security
Number(s), if applicable
B. Legal Authority
ORS 107.840
ORS 107.840
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.
Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the
document you are filing with the court. Check all boxes and complete all blanks that apply:
I selected this document for myself and I completed it without paid assistance.
I paid or will pay money to ________________________________ for assistance in
preparing this form.
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.
Date:_________________________ Signature:
OSB # (if applicable):
Type or Print Name:_______________________________
Page 1 – FORM 2.100.4c – AFFIDAVIT WITH REQUEST TO SEGREGATE SOCIAL
SECURITY NUMBERS ONLY – UTCR 2.100 (SHORT FORM) – (1/08)
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IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR THE COUNTY OF _________________
In the Matter of:
_________________________________
Petitioner,
and
_________________________________
Respondent.
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Case No. _________________
UTCR 2.100 SEGREGATED
INFORMATION SHEET SOCIAL SECURITY NUMBERS ONLY
(SHORT FORM)
ATTENTION COURT STAFF: The information set forth below must be kept separate 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: _______________________________________________________
Other contact information: __________________________________________________
Relationship to Case:
2.
Petitioner
Respondent
Other: ____________________
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: ________________________
Page 1 – FORM 2.100.4d – SEGREGATED INFORMATION SHEET – SOCIAL SECURITY NUMBERS ONLY –
UTCR 2.100 (SHORT FORM) – (1/08)
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