San Bernardino — 13-21907-360

Source: https://sanbernardino.courts.ca.gov/system/files/13-21907-360petitiontoobtainoriginalunsealedunredactedbirthcertificate.pdf

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY

TELEPHONE NO.: FAX NO.: EMAIL ADDRESS: ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: IN THE MATTER OF:

PETITION TO OBTAIN ORIGINAL UNSEALED/UN-REDACTED CASE NUMBER:
BIRTH CERTIFICATE

To request a copy of original birth certificate, complete this form and attach a copy of a valid photo identification or driver license.

1. Petitioner’s name and permanent residence address: ________________________________________________
___________________________________________________________________________________________

2. Adoptee’s date of birth and current age:
___________________________________________________________________________________________

3. Adoptee’s place of birth (city and state):
___________________________________________________________________________________________

4. Provide the following information:
a) Name of adoptive parents: __________________________________________________________________
b) Place of adoption (county in California): _______________________________________________________
c) Date of adoption: _________________________________________________________________________

5. I request permission to obtain a copy of original birth certificate of the named person for the following reasons:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________ □ Attachment to 5

6. Relationship to adopted individual: ______________________________________________________________

Form 13-21907-360 PETITION TO OBTAIN ORIGINAL UNSEALED/UN-REDACTED Health & Saf. Code §102705 Rev 08/18/16 BIRTH CERTIFICATE Family Code §9200

Name of Case: Case Number:

VERIFICATION

I am the petitioner in the above matter. I have read the foregoing Petition and know the contents thereof. I
declare that the same is true of my own knowledge, except as to those matters which are therein stated upon
my information and belief, and as to those matters I believe them to be true.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct

Executed on _________________________ at _____________________________________________________

SIGN

_______________________________________ _____________________________________________
Print Name Signature

Form 13-21907-360 PETITION TO OBTAIN ORIGINAL UNSEALED/UN-REDACTED Health & Saf. Code §102705 Rev 08/18/16 BIRTH CERTIFICATE Family Code §9200