MALHEUR COUNTY CIRCUIT COURT S.A.F.E. COURT PROGRAM Malheur County Courthouse 251 B Street West – PO Box 670 Vale, OR 97918 541/473-5568 S.A.F.E. COURT PROGRAM DECLINED State of Oregon vs. ____________________________________________________ Case Number(s) _______________________________________________________ I have been advised of the Court’s S.A.F.E. Court Program by the Court as well as my attorney, or a member of the SAFE Court Team. I have reviewed the Notice to Defendants and the S.A.F.E. Court Petition, Waiver and Agreement. I fully understand the opportunity it affords me and the responsibilities it would incur upon me. I further understand that an election to participate must be made today and an election to not participate will result in my case being placed on the regular docket for further proceedings. I further understand that I may not elect to participate in this program at any future date in this case. I hereby elect to not participate in the Circuit Court S.A.F.E. Court Program. ____________________________ ____________ _______________________________ Signed Name Date Print Name ____________________________ ____________ _______________________________ Attorney for Defendant Date Print Name OSB #______________________ American LegalNet, Inc. www.FormsWorkFlow.com