UTCR 2.100 Segregated Information Sheet
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UTCR 2.100 Segregated Information Sheet Form. This is a Oregon form and can be use in Uniform Trial Court Statewide.
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Tags: UTCR 2.100 Segregated Information Sheet, 2.100.4b, Oregon Statewide, Uniform Trial Court
IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR
COUNTY
Division (court’s address and phone number)
Case name:
)
)
)
)
)
)
Plaintiff Name
v.
ST
1
CASE No.
UTCR 2.100 SEGREGATED
INFORMATION SHEET
Defendant Name
ATTENTION COURT STAFF: Except as your trial court administrator tells you otherwise, this sheet
and its attachments are:
- to be separated from the attached request, 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:
2.
Protected personal information that is segregated:
Row
number
used to
identify
on
request
3.
General
description of the
protected
personal
information (same
as on request)
Relates to
(Person’s name)
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, e.g. social security number, 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:
Form 2.100.4b – UTCR 2.100 SEGREGATED INFORMATION SHEET – UTCR 2.100(4)(b) – page 1 with
attachments.
(Revised 8-1-10)
UTCR App. Page 4
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