Madera Superior Court Form Adopted for Optional Use MAD - JUV - 00 06 (Rev. 3/1 9 /19) PETITION TO INSPECT AND OR OBTAIN COPIES OF BIRTH RECORD Page 1 of 3 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address) (Telephone Number) ATTORNEY FOR (NAME): COURT USE ONLY SUPERIOR COURT OF CALIFORNIA 225 COUNTY OF MADERA Juvenile Division 200 South G Street Madera, CA 93637 In the Matter of the Petition of Adoption of: PETITION TO INSPECT AND OR OBTAIN COPIES OF BIRTH RECORD [HEALTH AND SAFETY CODE 102705] CASE NUMBER: THIS FORM IS TO BE USED TO PETITION THE COURT TO INSPECT OR COPY ADOPTION RECORDS MAINTAINED BY THE STATE DEPARTMENT OF SOCIAL SERVICES. DO NOT USE IF YOUR ADOPTION WAS A STEPPARENT ADOPTION. Type of adoption: Independent Agency I am the Petitioner and submit the following: 1. My name is: . 2. My mailing address is: . 3. My residence address is: County of: . 4. My telephone number is: . 5. My birth date is: . 6. I am now years old. 7. I am informed that an adoption proceeding related to (adoptee) was completed in the County of Madera, on or about by (adopting parents). Please check the box or boxes that apply: 8. For the reason stated on item 10, I request permission to obtain to inspect a copy of the original birth record maintained by the State Department of Social Services of the above referenced adoptee. I understand that if my request is granted the names and addresses of the birth parents and any information that might identify them will be removed from the documents or copies thereof. 9. For the reasons stated on item 10, I request the court to order the Office of Vital Records, Department of Health Services to unseal the original birth certificate of the above referenced adoptee, on which the names of the birth parents are stated. This information is necessary in order to assist me in establishing a legal right for the above referenced adoptee as set forth above. (Health and Safety Code 102705 requires a showing of necessity of the order and good and compelling cause. The name and address of the natural parents shall be given to the petitioner only if he or she can demonstrate that the name and address, or either of them, are necessary to assist him or her in establishing a legal right.) American LegalNet, Inc. www.FormsWorkFlow.com Madera Superior Court Form Adopted for Optional Use MAD - JUV - 00 06 (Rev. 3/1 9 /19) PETITION TO INSPECT AND OR OBTAIN COPIES OF BIRTH RECORD Page 2 of 3 10. Please state in complete detail all reasons for your request that apply in your case. (Attach additional pages if needed) 11. Attached is a copy of a government issued current photographic identification card of the petitioner. I request an order of the Superior Court as required by Health and Safety Code section 102705 with respect to the records relating to the above proceeding. Date: ( Signature of Petitioner ) VERIFICATION I am the petitioner in the above matter. I have read this petition and I know and understand what it states. I declare that the petition is true based upon my own personal knowledge, except as to those matters where it is stated to be based upon my information and belief, and as to those matters, I believe them to be true. I declare under penalty of perjury under the laws of the State of California that the above is true and correct. Date: ( Signature of Petitioner ) American LegalNet, Inc. www.FormsWorkFlow.com Madera Superior Court Form Adopted for Optional Use MAD - JUV - 00 06 (Rev. 3/1 9 /19) PETITION TO INSPECT AND OR OBTAIN COPIES OF BIRTH RECORD Page 3 of 3 TRANSMITTAL TO BE COMPLETED AND SENT BY CLERK OF THE COURT TO State Department of Social Services (Health and Safety Code 102705) STATE OF DEPARTMENT OF SOCIAL SERVICES Adoptions Branch 744 P Street, M/S 1931 Sacramento, CA 95814 To California State D.S.S.: The original petition seeking original birth records pursuant to Health and Safety Code section 102705 was filed in the Madera County Superior Court on . Please comply with Health and Safety Code section 102705 by sending to the Madera County Superior Court, attention: Adoptions Clerks, a copy of all records and information it has concerning the adopted person with the name and address of the natural parents removed. Clerk of the Superior Court of Madera County, Date: ( Deputy Clerk ) A copy of this request was sent by the Clerk of the Court Department of Social Services on . (Upon receipt of records from Department of Social Services, to be completed by Clerk of Court) To the Judge of Madera County Superior Court: Attached are the records received by Clerk of Court from the State Department of Social Services in response to this verified petition. Clerk of the Superior Court of Madera County, Date: ( Deputy Clerk ) American LegalNet, Inc. www.FormsWorkFlow.com