FORM 4 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LANE Case name: Co-Petitioner and Co-Petitioner ) ) ) ) ) ) ) ) ) ) CASE No. UTCR 2.100 AFFIDAVIT, 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, we 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 we 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 we 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. 4. 4. PERSON MAKING REQUEST MUST COMPLETE ALL THE FOLLOWING AS INDICATED: Page 1 of 4 - UTCR 2.100 AFFIDAVIT, REQUEST TO SEGREGATE PROTECTED PERSONAL INFORMATION FROM CONCURRENTLY FILED DOCUMENT 9A-CoPetitioners: UTCR2.100CoPet.wpd (12/03) American LegalNet, Inc. www.FormsWorkFlow.com 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) . We have segregated the information described above from another document or form that we are submitting at the same time, (describe document or form) to keep the protected information from being available to the general public. We 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. We (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 us of its response to this request. 4. (Initial to confirm) We 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, We 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) We 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. We 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 we knowingly provide false information to the court. Date Signature OSB# (if applicable) Type or print name Signature Type or print name For office use: Request granted OR denied (state reason) . Date: TRIAL COURT ADMINISTRATOR By_______________________________________ IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR LANE COUNTY Page 2 of 4 - UTCR 2.100 AFFIDAVIT, REQUEST TO SEGREGATE PROTECTED PERSONAL INFORMATION FROM CONCURRENTLY FILED DOCUMENT 9A-CoPetitioners: UTCR2.100CoPet.wpd (12/03) American LegalNet, Inc. www.FormsWorkFlow.com Case name: Co-Petitioner and Co-Petitioner ) ) ) ) ) ) ) ) ) ) CASE No. UTCR 2.100 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: Names: _________________________________________________________________ Address: _______________________________________________________________ Telephone number: _______________________________________________________ Other contact information: _________________________________________________ Relationship to case: ______________________________________________________ Page 3 of 4 - UTCR 2.100 AFFIDAVIT, REQUEST TO SEGREGATE PROTECTED PERSONAL INFORMATION FROM CONCURRENTLY FILED DOCUMENT 9A-CoPetitioners: UTCR2.100CoPet.wpd (12/03) American LegalNet, Inc. www.FormsWorkFlow.com 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) 3. There are attachments to this information sheet: If so, how many pages 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. Yes No For office use: Page 4 of 4 - UTCR 2.100 AFFIDAVIT, REQUEST TO SEGREGATE PROTECTED PERSONAL INFORMATION FROM CONCURRENTLY FILED DOCUMENT 9A-CoPetitioners: UTCR2.100CoPet.wpd (12/03) American LegalNet, Inc. www.FormsWorkFlow.com