Declaration In Support Of Petition To Establish Fact Time And Place Of Birth {MC-361A}

MC-361A ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: IN THE MATTER OF (Name): CASE NUMBER: DECLARATION IN SUPPORT OF PETITION TO ESTABLISH FACT, TIME, AND PLACE OF BIRTH (Name of declarant): HEARING DATE AND TIME: DEPT.: declares as follows: 1. I make the statements in this declaration based on my personal knowledge or on the contents of the documents identified in item 5. ("Personal knowledge" of a fact is knowledge that is not gained from another person's statements to you about that fact.) 2. a. I am at least 18 years of age. b. I reside at (street address and city): County: 3. (Name): approximately (time of birth): a. m. p. m. State: was born at on (date): at the following place: a. City, town, township, or other (identify "other" if known): b. c. County: State or province: are stated in the space below State (U.S.): Country: are stated in Attachment 4 to this declaration. 4. Facts showing when and where the person named in item 3 was born and explaining how I have personal knowledge of those facts (If you are relying solely on the contents of the documents identified in item 5, please advise in the space below.) Page 1 of 2 Form Adopted for Mandatory Use Judicial Council of California MC-361A [New July 1, 2012] DECLARATION IN SUPPORT OF PETITION TO ESTABLISH FACT, TIME, AND PLACE OF BIRTH (Miscellaneous) Health & Safety Code, §§ 103450­103490 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com MC­361A IN THE MATTER OF (Name): CASE NUMBER: 5. Attached are true and correct copies of the following documents (check each box that applies; statements of witnesses must be signed under oath, in an affidavit sworn before a Notary Public or with the following statement just above the signature: "I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct"): a. Hospital records dated (date of each): b. c. d. Physician's report dated (date of each): Witness statements dated (date of each): Other documents dated (describe and give the date of each document; "Other documents" could include school or college records, vaccination certificates and other medical records, employment records, documents showing sources of support other than employment, family correspondence, diaries, photographs, and other similar family records): Continued on Attachment 5d. 6. The birth of the person named in item 3, or the date, time, or place of birth is not is important to a court case or proceeding that is now pending and described below. (If you selected "is," briefly describe the proceeding and provide the case name and number, the name and address of the court where the proceeding is pending, the names of all parties to the proceeding, and the names, addresses, and telephone numbers of their attorneys. Note: A court order made on a petition under Health and Safety Code section 103450, et seq., may not be effective against claims of persons or organizations not given notice of the petition for the order.) Continued on Attachment 6. 7. Number of pages attached: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: (TYPE OR PRINT NAME OF DECLARANT) MC-361A [New July 1, 2012] (SIGNATURE OF DECLARANT) Page 2 of 2 DECLARATION IN SUPPORT OF PETITION TO ESTABLISH FACT, TIME, AND PLACE OF BIRTH (Miscellaneous)