PETITION TO ESTABLISH FACT OF BIRTH GCSC PR-003 1 of 2 1. Petitioner (name): Is a beneficially interested person, entitled under Health and Safety Code 103450 to an order establishing the fact and the date and place of the birth of the person named in item 3. 2. Petitioner222s beneficial interest in this matter is stated below stated in attachment 2. 3. Petitioner requests the court to establish the birth of: a. Name: Gender: Male Female b. Father222s name: Mother222s name: c. Date of birth: Time: d. Place of birth: City: County: State: Country: 4. (Check one of the following): a. There is no official record of the fact, date, and place of the birth of the person named in item 3. b. A certified copy of the official record of the birth of the person named in item 3 cannot be obtained for the reasons stated below stated in attachment 4b. 5. The person named in number 3 now resides at (street address, city, county, and state): ATTORNEY OR PARTY WITHOUT ATTORNE Y (Name, State Bart number, and address): FOR COURT USE ONLY TELEPHONE NO.: FAX NO. (Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF GLENN 526 West Sycamore Street, Willows, CA 95988 IN THE MATTER of (Name): CASE NUMBER PETITION TO ESTABLISH FACT OF BIRTH American LegalNet, Inc. www.FormsWorkFlow.com PETITION TO ESTABLISH FACT OF BIRTH GCSC PR-003 2 of 2 6. Petitioner requests that the court make an order determining that the birth of the person named in item 3 did in fact occur on the date and at the place stated in item 3 above, as shown by the Declaration in Support of Petition to Establish Fact of Birth (Form MC-031). Filed herewith, and by proof offered as evidence to this court. 7. Number of pages attached: I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Date: IN THE MATTER OF (NAME): CASE NUMBER American LegalNet, Inc. www.FormsWorkFlow.com