ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, address and telephone #): FOR COURT USE ONLY STATE BAR NO: ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF MARIN 3501 Civic Center Drive P.O. Box 4988 San Rafael, CA 94913-4988 IN THE MATTER OF THE PETITION OF: TO ESTABLISH THE FACT OF BIRTH OF: CASE NUMBER: PETITION TO ESTABLISH FACT OF BIRTH 1. Petitioner is a beneficially interested person, entitled under section 103450 of the California Health and Safety Code, to judicial establishment of the fact, time and place of the birth of (name of individual): Petitioner’s beneficial interest in the matter herein is based on the following facts and circumstances (state relationship, if any, and other facts and circumstances giving rise to or affecting a beneficial interest (Attach additional sheets if necessary) 2. A certified copy of the record of birth of (name of individual) ________________________________ is not registered. 3. On (date) ___________________________________________ , the birth of (name of individual) occurred in County of ______________________ State of _________________________. (If place of birth is unknown then indicate all of the facts known about the birth including a statement of the probable time and place of birth.) Wherefore petitioner prays that a time and place be fixed for the hearing of the petition and that on the hearing of this petition the Court make an order determining that the birth did in fact occur at the time and place by the proofs adduced at said hearing. (Your name) ________________________________________________, being duly sworn, deposes and says: That he/she is the petitioner named in the foregoing petition; that he/she has read the foregoing petition and knows the contents thereof; that the same is true of his/her own knowledge except as to the matters which are therein stated upon his/her information or belief, and as to those matters that he/she believes it to be true. Date: _______________________________________ SIGNATURE CV018WB (Rev. 7/07) PETITION TO ESTABLISH FACT OF BIRTH Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Name: Case Number: AFFIDAVIT OF BIRTH PERSONAL AND STATISTICAL PARTICULARS Full name of child Date of birth Place of birth Sex of child Full name of father Father’s residence at child’s birth Father’s age at child’s birth Father race Father’s birthplace Fathers occupation at child’s birth Full maiden name of mother Mother’s residence at child’s birth Mother’s age at child’s birth Mother race Mother’s birthplace Mothers occupation at child’s birth I certify that I am the (state relationship) ____________________________________________ of this child who was born on the date above stated. This affidavit must be notarized or signed before a clerk of the court. Affiant Subscribed and sworn before me this ____________________ day of Address KIM TURNER Court Executive Officer By DEPUTY CV018WB (Rev. 7/07) PETITION TO ESTABLISH FACT OF BIRTH Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com