American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR COUNTY Division - (court222s address and phone number) Case name: Plaintiff Name v. 1st Defendant Name ) ) ) ) ) CASE No. REQUEST TO INSPECT UTCR 2.100 SEGREGATED INFORMATION SHEET By this form, I request to see or obtain a copy of part or all of a UTCR 2.100 Segregated Information Sheet (SIS) that is being withheld from the public. I have completed this form to provide the information the court requires of me to make this request. I understand the court will not automatically grant this request but will use applicable law to decide whether I have a right to see or copy the information I request. I understand this request will be a public record whether or not granted. 1. Information about me: a. My Name: b. My Address: c. My Telephone number: d. Other contact information for me: e. I believe I have a legal right to see the information because (explain reasons): 2. To identify the UTCR 2.100 Segregated Information Sheet (SIS) I am requesting: a. Name of person who submitted request for SIS: b. Date request submitted: c. Description of document from which information is segregated: d. General description(s) of protected personal information I am requesting to see (use same general description as on request in file): e. Row number(s) of description of this information on request: f. Name of person to whom information relates (if known): g. The request for the SIS shows that the SIS includes other information I am not requesting to inspect or copy (check one) Yes OR No. (If Yes, this other information will be redacted) Page 1 - Form 2.100.8 226 REQUEST TO INSPECT UTCR 2.100 SEGREGATED INFORMATION SHEET 226 UTCR 2.100(8) (Revised 8-1-10) American LegalNet, Inc. www.FormsWorkFlow.com 3. Confirming additional requirements completed: a. (Initial to confirm, 223na224 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 request and the attached form as required by UTCR 2.010(7). b. (Initial to confirm) I have mailed or delivered copies of this request to the following persons required by UTCR 2.080 (list names): . c. (Initial to confirm) I understand that I will be responsible for any costs resulting from the court responding to this request except those costs for which I have obtained a waiver, and will advance money to cover those costs if requested by the court. I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury. Date Signature OSB# (if applicable) Type or print name For Office use: Request to inspect granted OR denied (state reason) Related comments: Date: TRIAL COURT ADMINISTRATOR By Page 2 - Form 2.100.8 226 REQUEST TO INSPECT UTCR 2.100 SEGREGATED INFORMATION SHEET 226 UTCR 2.100(8) (Revised 8-1-10)