CI-130 ATTORNEY OR PARTY WITHOUT ATTORNEY NAME: FIRM NAME: ADDRESS: CITY: E-MAIL ADDRESS (OPTIONAL): ATTORNEY FOR (NAME): STATE: ZIP CODE: TELEPHONE NO: FAX NO. (OPTIONAL): STATE BAR NO: FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF MONTEREY Monterey Division -1200 Aguajito Road, Monterey, California 93940 PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: CONFIDENTIAL DECLARATION REGARDING HOUSEHOLD MEMBERS CASE NUMBER: I, , declare: I am the Petitioner and proposed guardian in this proceeding. The members of my household who are sixteen years of age or older are as follows: Name of Person Date of Birth Social Security Number Driver License Number I declare under penalty of perjury under the laws of the State of California that the foregoing is true at (city) , and correct. Executed on (date) California. Type or Print Name Form Approved for Mandatory Use CI-130 New. September, 2013 Signature of Declarant CONFIDENTIAL DECLARATION REGARDING HOUSEHOLD MEMBERS (CIVIL) Monterey County Superior Court American LegalNet, Inc. www.FormsWorkFlow.com