(Court use only) Petition to Obtain Information From Original Birth Record-Adoptee Health and Safety Code Section 102705 If this document is executed outside of the State of California, The affidavit of verification is to be executed before a notary public or other officer authorized to administer oaths. Address: Superior Court of California, County of San Mateo Juvenile Division 222 Paul Scannell Drive San Mateo, CA 94402 www.sanmateocourt.org Phone number: Case # My name is: Date of birth: _______________ I am informed and believe that I was adopted by _____________________________________________ (complete first and last names) The adoption took place in the County of San Mateo on or about ________________________________ (date) Please check the box or boxes that apply: Pursuant to Health and Safety Code §102705  I request permission to inspect my original birth record for the reasons set forth in the attached declaration. I understand that if my request is granted the names and addresses of the birth parents or any information that might identify them will be removed from the documents or copies thereof.  I request the court to order the Office of Vital Records, Department of Health Services to unseal the original birth certificate, on which the names of my birth parents are stated. This information is necessary in order to assist me in establishing a legal right as set forth in the attached declaration. You must attach a detailed declaration stating the reasons for your request. If you checked both boxes above you must provide a separate declaration for each request. AFFIDAVIT OF VERIFICATION I am the applicant in the foregoing matter. I have read the foregoing application and know the contents thereof. I certify or declare under penalty of perjury that the foregoing is true and correct. Print Name Signature Executed this ___________ day of ________________ 20____ at ADOPT-9 (updated 3-30-11) American LegalNet, Inc. www.FormsWorkFlow.com