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AFFIDAVIT WITH REQUEST TO SEGREGATE SOCIAL SECURITY NUMBERS ONLY – UTCR 2.100 (SHORT FORM) - FORM 2.100.4c - PAGE 1 OF 1 Disso 1BC: SSOnly AffidReq.doc (1/08) IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF In the Matter of: ) ) Case No. , ) Petitioner, ) UTCR 2.100 AFFIDAVIT WITH ) REQUEST TO SEGREGATE and ) SOCIAL SECURITY NUMBERS ONLY ) (SHORT FORM) , ) Respondent. ) 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 □ Petitioner’s Social Security Number ORS 107.840 □ Respondent’s Social Security Number ORS 107.840 □ Child/ren’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 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: SEGREGATED INFORMATION SHEET – SOCIAL SECURITY NUMBERS ONLY - UTCR 2.100 (SHORT FORM) – FORM 2.100.4d – PAGE 1 OF 1 Disso1B: SegInfoOnly.doc (1/08) IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF In the Matter of: ) ) Case No. , ) Petitioner, ) UTCR 2.100 SEGREGATED ) INFORMATION SHEET – and ) SOCIAL SECURITY NUMBERS ONLY ) (SHORT FORM) , ) Respondent. ) 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: ☐ Petitioner ☐ Respondent ☐ Other: 2. Segregated Social Security Numbers: Petitioner Name: SSN: Respondent Name: SSN: Child/ren of the parties (if applicable): Name: SSN: Name: SSN: Name: SSN: Name: SSN: Name: SSN: