San Bernardino — 13-21909-360

Source: https://sanbernardino.courts.ca.gov/system/files/13-21909-360petitionforbirthrecordinformation.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 FOR BIRTH RECORD INFORMATION CASE NUMBER:

To request birth record information and/or copies of birth records, complete this form and attach a copy of a valid photo identification or driver license.

1. Adoptee’s name: _____________________________________________________________________________

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

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

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

Complete in detail all reasons for your request that apply in your case. Attach additional pages if necessary. Reasons may include, medical or health, legal, search for missing person or other reasons.

5. I request permission to inspect the records and/or obtain copies of records relating to the birth of the named
person for the following reasons: ________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________ □ Attachment to 5

Form 13-21909-360 PETITION FOR BIRTH RECORD INFORMATION Health & Saf. Code §102705 Rev 10/4/16 Family Code §8619, 9200

Name of Case: Case Number:

6. I request the birth record information relating to the birth of the named person be unsealed and/or un-
redacted for the following reasons: ______________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
____________________________________________________________________________ □ Attachment to 6

7. I am requesting copies of documents pertaining to the degree of Indian blood and tribal enrollment and/or the
certificate of degree of Indian blood, and one of the following is true, Family Code §8619:

□ a) These documents are required by the Bureau of Indian Affairs to determine the adoptee’s eligibility to receive services or benefits because of the adoptee’s status as an Indian. □ b) I am the adoptee, and I am 18 years of age or older.

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 13-21909-360 PETITION FOR BIRTH RECORD INFORMATION Health & Saf. Code §102705 Rev 10/4/16 Family Code §8619, 9200