IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF __________________ _____________ Division – _____________________________________________ (court’s address and phone number) In the matter of: __________________________________ Petitioner and __________________________________ Respondent ) ) ) ) ) ) ) ) ) ) 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 American LegalNet, Inc. INFORMATION FROM CONCURRENTLY FILED DOCUMENT - Page 1 of 4 www.FormsWorkFlow.com Contempt-19: - UTCR2.100Long-Ver01.doc (3/08) 4. 4. 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 American LegalNet, Inc. INFORMATION FROM CONCURRENTLY FILED DOCUMENT - Page 2 of 4 www.FormsWorkFlow.com Contempt-19: - UTCR2.100Long-Ver01.doc (3/08) 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 ) ) ) ) ) ) ) ) ) ) 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 American LegalNet, Inc. INFORMATION FROM CONCURRENTLY FILED DOCUMENT - Page 3 of 4 www.FormsWorkFlow.com Contempt-19: - UTCR2.100Long-Ver01.doc (3/08) 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 American LegalNet, Inc. INFORMATION FROM CONCURRENTLY FILED DOCUMENT - Page 4 of 4 www.FormsWorkFlow.com Contempt-19: - UTCR2.100Long-Ver01.doc (3/08)