SHERRI . CARTER EXECUTIVE OFFICER/CLERK OF SUPERIOR COURT ADOPTION UNIT, ROOM 2100 201 CENTRE PLAZA DRIVE MONTEREY PARK, CA 91754 Superior Court of the State of California, County of Los Angeles PETITION FOR BIRTH RECORD INFORMATION Section 102705 Health and Safely Code NAME: DATE OF BIRTH AGE PERMANENT RESIDENCE STREET: CITY: ZIP: I AM INFORMED AND BELIEVE THAT I WAS ADOPTED BY: IN THE COUNTY OF: , STA TE OF CALIFORNIA AND: APPROXIMATE DATE OF ADOPTION: OR 226 I AM INFORMED THAT AN ADOPTION PROCEEDING RELATING TO: ADOPTEE: BY: WAS COMPLETED IN: COUNTY, STATE OF CALIFORNIA APPROXIMATE DATE OF ADOPTION: AND: ADOPTIVE PETITIONERS MY RELATION TO SAID PERSONS IS AS FOLLOWS: (STATE RELATION TO ADOPTEE AND ADOPTIVE PET ITIONERS) I REQUEST PERMISSION TO INSPECT THE RECORDS AND OR OBTAIN COPIES OF RECORDS RELATING TO THE BIRTH OF THE NAMED PERSON FOR THE FOLLOWING REASONS: (SECTION 102705 HEALTH AND SAFETY CODE REQUIRES 223GOOD AND COMPELLING CAUSE224 WHEREFORE, I REQUEST AN ORDER OF THE SUPERIOR COURT AS REQUIRED BY SECTION 102705 OF THE HEALTH AND SAFETY CODE WITH RESPECT TO THE RECORDS RELATING TO THE ABOVE PROCEEDING. (SIGNATURE) VERIFICATION STATE OF CALIFORNIA ) ) SS. COUNTY OF LOS ANGELES ) I am the Petitioner in the above matter, I have read the foregoing Petition and know the contents thereof; I declare that the same is true of my own knowledge, except as to those matters which are therein stated upon my information and belief, and as to those matters I believe it to be true. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dated this day of , 20 at . (LOCATION) (SIGNATURE) American LegalNet, Inc. www.FormsWorkFlow.com THE STATE DEPARTMENT OF SOCIAL SERVICES 744 223P224 STREET M/S 19-67 SACRAMENTO, CA 95814 The original of the above petition was filed in the office of the undersigned on , 20 . Please comply with the provisions of Section 102705 of the Health and Safety Code. LOS ANGELES SUPERIOR COURT ADOPTION UNIT, ROOM 2100 201 CENTRE PLAZA DRIVE MONTEREY PARK, CA 91754 SHERRI A. CARTER , EXECUTIVE OFFICER/CLERK OF THE SUPERIOR COURT COUNTY OF LOS ANGELES, STATE OF CALIFORNIA BY: , Deputy CLERKS NOTATION Copy transmitted to the State Department of Social Services on: to the above entitled Court on . Attached thereto are the records received by the undersigned from the State Department of Social Services, after transmission of a copy of the above verified petition to said Department as aforesaid. SHERRI A. CARTER , EXECUTIVE OFFICER/CLERK OF THE SUPERIOR COURT COUNTY OF LOS ANGELES, STATE OF CALIFORNIA BY: , Deputy COURT ORDER The Court, having reviewed all of the attached records received from the State Department of Social Services and the foregoing verified Petition, and finding that good and compelling cause exists therefore, now makes the following order: THE CLERK IS ORDERED TO FURNISH PETITIONER WITH A COPY OF THE FOLLOWING DOCUMENTS, UPON PAYMENT OF ANY FEES REQUIRED BY LAW: THE CLERK IS ORDERED TO PERMIT PETITIONER TO EXAMINE THE FOLLOWING RECORDS: DATE: JUDGE OF THE SUPERIOR COURT American LegalNet, Inc. www.FormsWorkFlow.com