ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number, Address) Reserved for Clerk's Office Stamp TELEPHONE NO: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO.(Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO Youth Services Center, Juvenile Court 222 Paul Scannell Drive San Mateo, CA 94402 IN RE: CASE NUMBER: Petition to Obtain Information From Original Birth Record - Interested Party Health and Safety Code Section 102705 My name is:________________________________________________ Relationship to adoptee/adoptive parents: ___________________________ Phone number: ______________________ Address: ________________________________________________________________________________________ Email Address: ____________________________________________ I am informed that an adoption proceeding relating to__________________________________________________ (complete first and last name and date of birth) was completed in the County of __________________________ on or about _______________________________. (month-date-year) Names of the adoptive parents; Mother__________________________________________ Father_______________________________________ (complete first and last names) (complete first and last names) Type of adoption: ___ Step Parent ___ Independent ___ County ___ Agency ___ Adult Please check the box or boxes that apply: I request permission to inspect the original birth record of the above referenced adoptee for the reasons set forth in the attached declaration. 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. 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 in attached declaration. You must attach a detailed declaration stating the reasons for your request. If you checked both boxes above you must provide a separate declaration for each request. Page 1 of 2 Form adopted for Mandatory Use Petition to Obtain Information From Original Birth Record - Interested Party Health & S. C. § 102705 www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com Local Court Form Adopt-10 [Revised Sept. 2012] AFFIDAVIT OF VERIFICATION * I am the applicant in the foregoing matter. I have read the foregoing application and know the contents thereof. I certify or declare under penalty of perjury that the foregoing is true and correct. Print Name Signature Executed this ___________ day of ________________ 20____ at _________________________________________ Include a self-addressed stamped envelope if you wish to receive a copy of the final order, standard copy and certification charges will apply. * If this document is executed outside of the State of California, the affidavit of verification is to be executed before a notary public or other officer authorized to administer oaths. Page 2 of 2 Form adopted for Mandatory Use Petition to Obtain Information From Original Birth Record - Interested Party Health & S. C. § 102705 www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com Local Court Form Adopt-10 [Revised Sept. 2012]