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Declaration In Support Of Petition To Establish Fact Time And Place Of Death Form. This is a California form and can be use in Miscellaneous Judicial Council.
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Tags: Declaration In Support Of Petition To Establish Fact Time And Place Of Death, MC-360A, California Judicial Council, Miscellaneous
MC-360A
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
FOR COURT USE ONLY
FAX NO. (Optional):
TELEPHONE NO.:
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CASE NUMBER:
IN THE MATTER OF
(Name):
HEARING DATE AND TIME:
DECLARATION IN SUPPORT OF PETITION TO
ESTABLISH FACT, TIME, AND PLACE OF DEATH
(Name of declarant):
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:
State:
died at
3. (Name of deceased person):
approximately (time):
a.m.
p.m.
on (date):
at the following place:
a. City, town, township, or other (identify “other” if known):
b.
County:
c.
State or province:
State (U.S.):
Country:
4. Facts showing how, when, and where the person named in item 3 died and explaining how I have personal knowledge of those facts
are stated in Attachment 4 to this declaration.
are stated in the space below
(If you are relying solely on the contents of the documents identified in item 5, please advise in the space below.)
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Form Approved by the
Judicial Council of California
MC-360A [Rev. July 1, 2012]
Mandatory Form [7/1/2012]
DECLARATION IN SUPPORT OF PETITION TO
ESTABLISH FACT, TIME, AND PLACE OF DEATH
Health & Safety Code, §§ 103450–103490
www.courts.ca.gov
(Miscellaneous)
American LegalNet, Inc.
www.FormsWorkFlow.com
MC–360A
IN THE MATTER OF
CASE NUMBER:
(Name):
5.
Attached are true and correct copies of the following documents (check each box that applies):
a.
Police report dated (date of each):
b.
Coroner’s report dated (date):
c.
Private physician's report dated (date of each):
d.
Other documents dated (describe and give the date of each document):
Continued on Attachment 5d.
is not
is important to a court case or
6. The death of the person named in item 3, or the date, time, or place of death
proceeding that is 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-360A [Rev. July 1, 2012]
(SIGNATURE OF DECLARANT)
DECLARATION IN SUPPORT OF PETITION TO
ESTABLISH FACT, TIME, AND PLACE OF DEATH
(Miscellaneous)
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