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Affidavit With Request To Segregate Social Security Numbers Only - Oregon
| Affidavit With Request To Segregate Social Security Numbers Only Form. This is a Oregon form and can be used in Divorce Circuit Court Lincoln Local County . |
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IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINCOLN In the Matter of: ___________________________________ Petitioner, and ___________________________________ Respondent. ) ) ) ) ) ) ) ) ) ) ) Case No. UTCR 2.100 AFFIDAVIT WITH REQUEST TO SEGREGATE SOCIAL SECURITY NUMBERS ONLY (SHORT FORM) 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 Petitioner's Social Security Number Respondent's Social Security Number Child/ren's Social Security Number(s), if applicable B. Legal Authority ORS 107.840 ORS 107.840 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 knowingly give the information in this affidavit and the attached information sheet under an oath or affirmation attesting to the truth of what is stated and subject to sanction by law if I knowingly provide false information to the court. 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 (SHORT FORM) (1/08) American LegalNet, Inc. www.FormsWorkflow.com 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 SEGREGATED INFORMATION SHEET SOCIAL SECURITY NUMBERS ONLY (SHORT FORM) ATTENTION COURT STAFF: The information set forth below must be kept separate from the applicable court file and may not be shown to any member of the public except by order of the court. 1. Requestor Information (Contact address and telephone number may be used): Name: __________________________________________________________________ Address: ________________________________________________________________ Telephone Number: _______________________________________________________ Other contact information: __________________________________________________ Relationship to Case: 2. Petitioner Respondent Other: ____________________ Segregated Social Security Numbers: Petitioner Name:__________________________ Respondent Name:________________________ Child/ren of the parties (if applicable): Name:______________________________ Name:______________________________ Name:______________________________ Name:______________________________ Name:______________________________ SSN:________________________ SSN: ________________________ SSN: ________________________ SSN: ________________________ SSN: ________________________ SSN: ________________________ SSN: ________________________ Page 1 FORM 2.100.4d SEGREGATED INFORMATION SHEET SOCIAL SECURITY NUMBERS ONLY UTCR 2.100 (SHORT FORM) (1/08) American LegalNet, Inc. www.FormsWorkflow.com
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