Form 150-303-005 - County Disclosure Form/certificate Of Confidentiality Page 3

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County Disclosure Form
Certificate of Confidentiality
Certificate Required by ORS 308.413(3)
I certify that I have read the following provisions of law prohibiting disclosure of confidential information, that they
have been explained to me and that I understand them and the penalties for violation of these laws:
ORS 308.290(11)
ORS 308.413
ORS 308.990(5)
Print full name
X
Signature
Date
Print name of county
Witness (supervisor of employee)
150-303-005 (Rev. 10-10)
County Disclosure Form, page 1 of 1

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