American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR COUNTY Division - Case name: Plaintiff Name v. 1 ST Defendant Name ) ) ) ) ) ) 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 maintained separately from the attached request, and - NOT placed in any court file where they can be seen by the public, and - NOT 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: 2. Protected personal information that is segregated: Row number used to identify on request General description of the protected personal information ( same as on request ) Relates to ( ) The following is the specific Protected Personal Information to be segregated ( give the specific fact, e.g. S ocial S ecurity number, that is being protected). This can be a reference to an attachment. Do not use for contact information ( addresses, telephone numbers, employer identification, an d 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: Form 2.100.4b UTCR 2.100 SEGREGATED INFORMATION SHEET UTCR 2.100(4)(b) page 1 with pages of attachments. (Revised 5-15-12)