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Affidavit With Request To Segregate Social Security Number(s) Only - Oregon
| Affidavit With Request To Segregate Social Security Number(s) Only Form. This is a Oregon form and can be used in Circuit Court Jackson Local County . |
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DOCUMENT 3B - 4 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY ) ) ) ) ______________________________ ) Petitioner, ) ) vs. ) ) ______________________________ ) Respondent. ) _________________________________ ) In the Matter of: the Marriage of the Domestic Partnership of CASE NO.__________________________ UTCR 2.100 AFFIDAVIT WITH REQUEST TO SEGREGATE SOCIAL SECURITY NUMBER(S) 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 the general public can view. The Social Security number(s) I request be segregated is/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. 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. Dated:_________________________ Signed:_________________________________ Name:__________________________________ (Please Print) Address:________________________________ _________________________________ Phone:__________________________________ UTCR 2.100 AFFIDAVIT/REQUEST TO SEGREGATE SOCIAL SECURITY NUMBER(S) ONLY - PAGE 1 OF 1 (11/26/08) OJIN CODE: AFSI_____ (SHORT FORM) FORM 2.100.4c American LegalNet, Inc. www.FormsWorkFlow.com
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