SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE BLYTHE 265 N. Broadway, Blythe, CA 92225 HEMET 880 N. State St., Hemet, CA 92543 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address) INDIO 46-200 Oasis St., Indio, CA 92201 RIVERSIDE 4175 Main St., Riverside, CA 92501 RI-FL040 FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): PETITIONER: RESPONDENT: CASE NUMBER: CERTIFICATE OF ASSIGNMENT (SURROGACY) The undersigned declares that the above-entitled matter is filed for proceedings in the following region of the Superior Court under local rule 5101: Blythe Hemet Indio Riverside Gestational Carriers. Pursuant to FC § 7962(e), an action to establish the parent-child relationship between the intended parent or parents and the child as to a child conceived pursuant to an assisted reproduction agreement for gestational carriers may be filed before the child's birth. The undersigned certifies that this case should be tried or heard in the County of Riverside because: (check all that apply) 1. 2. 3. 4. 5. It is anticipated that the child will be born in the county. The intended parent or intended parents reside in the county. The surrogate resides in the county. The assisted reproduction agreement for gestational carriers was executed in the county. The medical procedures pursuant to the agreement are to be performed in the county. Traditional Surrogate: Pursuant to FC § 7620(b)(1), an action to establish the parent-child relationship should be tried or heard in the County of Riverside because the child resides or is found in the county. Traditional surrogate means a woman who agrees to gestate an embryo, in which the woman is the gamete donor and the embryo was created using the sperm of the intended father or a donor arranged by the intended parent or parents. I declare under penalty of perjury under the laws of the State of California that the information above is true and correct. Date: (TYPE OR PRINT NAME OF ATTORNEY PARTY MAKING DECLARATION) (SIGNATURE) Page 1 of 1 Approved for Mandatory Use Riverside Superior Court RI-FL040 [Rev. 01/01/16] CERTIFICATE OF ASSIGNMENT (SURROGACY) FC§ 7962(e) riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com