San Luis Obispo — FL016

Source: https://www.slo.courts.ca.gov/system/files/forms-and-filings/fl016-surrogacy-judgment-checklist.pdf

NAME, ADDRESS AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER Reserved for Clerk’s File Stamp

ATTORNEY FOR (NAME): EMAIL:
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN LUIS OBISPO
COURT HOUSE ADDRESS:

PETITIONER / PLAINTIFF

RESPONDENT / DEFENDANT

OTHER

CASE NUMBER: DEPT. NUMBER:
SURROGACY JUDGMENT CHECKLIST DATE PETITIONED:

SUBJECT MATTER JURISDICTION COMPLIANCE WITH FAMILY CODE 7962 The Court has jurisdiction in this proceeding to determine If a case does not technically meet all of the requirements parentage of the child pursuant to Family Code Section of Family Code Section 7962, then under Family Code 7620(b) because (check all that apply): Section 7962(f)(2), the court is not prevented from the Petitioner(s) reside(s) in this state; entering a parentage order, so long as the parties have the Petitioner(s) resided in this state at the time the provided sufficient proof entitling them to the relief assisted reproduction agreement for gestational sought. However, in this case, the parties have complied carriers was executed; with all the requirements of Family Code Section 7962 the Respondent(s) reside(s) in this state; for the reasons stated below: the Respondent(s) resided in this state at the time the assisted reproduction agreement for gestational 1) 7962(a) The assisted reproduction agreement for carriers was executed; gestational carriers contains: the medical procedures leading to conception, (1) the date on which the assisted reproduction including in vitro fertilization or embryo transfer, or agreement for gestational carriers was executed; both, were carried out in this state; and/or the child was/is expected to be born in this state. (2) the persons from which the gametes originated (unless anonymously donated, in which case the donated gametes are identified in the agreement) VENUE Source of Ova: Intended Parent(s): Venue is proper before this Court pursuant to Family Code Donor Sections 7620(c)(5) and 7962(e) because (check all that Source of Sperm: apply): Intended Parent(s): Donor; it is anticipated the child(ren) will be born in this county; the intended parent(s) reside(s) in this county; (3) the identity, or identities, of the intended parents; the gestational surrogate resides in this county; and the assisted reproduction agreement for gestational (continued on next page) carriers was executed in this county; and/or the medical procedures pursuant to the assisted reproduction agreement for gestational carriers were performed in this county.

FL016 Adopted 7/24 SURROGACY JUDGMENT CHECKLIST Page 1 of 2 Mandatory

The following documents are submitted in support of this (4) disclosure of how the intended parent(s) will cover action to establish a parent-child relationship: the medical expenses of the gestational carrier and newborn(s). Any health care coverage used to Judicial Council Forms: cover the medical expenses was reviewed for any FL-105 UCCJEA -- Petitioner(s) possible liability of the gestational carrier, including FL-105 UCCJEA -- Respondent(s) any third-party liability liens or other insurance FL-130 Appearance, Stipulation, and Waivers coverage, and any notice requirements that could FL-190 Notice of Entry of Judgment affect coverage or liability of the gestational carrier. FL-200 Petition to Determine Parental Relationship If coverage of liability was uncertain at the time of FL-210 Summons execution, a statement of that fact is included in theassisted reproduction agreement for gestational FL-220 Response to Petition to Determine Parental carriers. Relationship FL-230 Declaration for Default or Uncontested Judgment -- Petitioner(s) 2) 7962(b) Prior to executing the written assisted FL-230 Declaration for Default or Uncontested reproduction agreement for gestational carriers, the Judgment -- Respondent(s) surrogate and the intended parent(s) were represented by FL-235 Advisement and Waiver of Rights -- Petitioner(s) separate independent licensed attorneys of their choosing. FL-235 Advisement and Waiver of Rights -- Respondent(s) FL-240 Stipulation for Entry of Judgment 3) 7962(c) The assisted reproduction agreement for FL-250 Judgment gestational carriers was executed by the parties in the Attachment 5h to FL-250 presence of a Notary Public, or witnessed by an equivalent method of affirmation as required in the jurisdiction the Long Forms: agreement was executed in. Declaration(s) of Petitioner(s) Declaration(s) of Respondent(s) 4) 7962(d) The parties did not undergo an embryo transfer Declaration of IVF Physician procedure, or commence injectable medication in Declaration of Attorney for Petitioner(s) preparation for an embryo transfer until the assisted Declaration of Attorney for Respondent(s) reproduction agreement for gestational carriers was fully executed as required by Family Code Sections 7962(b) and Other: 7962(c). A Copy of the assisted reproduction agreement for gestational carriers has been executed, notarized 5) 7962(e) A copy of the assisted reproduction agreement (or the equivalent), and is lodged with the Court. for gestational carriers has been lodged with this court. A true and accurate copy is acceptable. 6) 7962(e) The parties have attested, under penalty of Criminal Background Check(s) for Petitioner(s) perjury and to the best of their knowledge and belief, as to Order Sealing Records (if requested) is: their compliance with Family Code Section 7962 in entering Filed as a separate Order into the assisted reproduction agreement. Included in Attachment 5h to the FL-25

Filing Fees:
$435 Filing Fee for Petitioners
$435 Filing Fee for Respondents

I declare under penalty of perjury of the law of the Status of California that the foregoing is true and correct.

Signature Date
CA Bar #:
Attorney for Petitioners

FL016 Adopted 7/24 SURROGACY JUDGMENT CHECKLIST Page 2 of 2 Mandatory