UTCR 2.100 Affidavit With Request To Segregate Social Security Numbers Only
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UTCR 2.100 Affidavit With Request To Segregate Social Security Numbers Only Form. This is a Oregon form and can be use in Uniform Trial Court Statewide.
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Tags: UTCR 2.100 Affidavit With Request To Segregate Social Security Numbers Only, 2.100.4c, Oregon Statewide, Uniform Trial Court
IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR THE COUNTY OF _________________
In the Matter of:
)
)
________________________________, )
Petitioner,
)
)
and
)
)
________________________________, )
Respondent.
)
Case No. ____________________
UTCR 2.100 AFFIDAVIT WITH
REQUEST TO SEGREGATE SOCIAL
SECURITY NUMBERS ONLY
By this affidavit under UTCR 2.100 and as required by ORS 107.840, I request that the social
security number(s) in the attached “Segregated Information Sheet” be segregated (kept
separate) from information that the general public can see. The social security numbers that I
request be segregated are as follows:
A. Protected Personal Information
B. Legal Authority
G Petitioner’s Social Security Number
ORS 107.840
G Respondent’s Social Security Number
ORS 107.840
G Child/Children’s Social Security
Number(s), if applicable
ORS 107.840
I have mailed or delivered copies of this request (not including the attached information
sheet) to the opposing party in this matter.
Certificate of Document Preparation. You are required to truthfully complete this certificate
regarding the document you are filing with the court. Check all boxes and complete all blanks
that apply:
‘ I selected this document for myself and I completed it without paid assistance.
‘ I paid or will pay money to ________________________________ for assistance in
preparing this form.
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:
Page 1 - Form 2.100.4c – AFFIDAVIT WITH REQUEST TO SEGREGATE SOCIAL SECURITY NUMBERS ONLY – UTCR 2.100
(Revised 8-1-05)
UTCR App. Page 5
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