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: REQUEST TO OBTAIN INFORMATION FROM ORIGINAL BIRTH RECORD ADOPTEE ­ HEALTH AND SAFETY CODE SECTION 102075 My name is: ___________________________________________________________________ Date of birth: _____________ Phone number: __________________________________ Address: ________________________________________________________________________________________ Email Address: _____________________________________________ I am informed and believe that I was adopted by: Mother _________________________________________________ (complete first and last name) Father: _____________________________________________________ The adoption took place in (complete first and last name) the County of ______________________________on or about ____________________________________________ (month-date-year) Type of adoption: ___ Step Parent ___ Independent ___ County ___ Agency _____ Adult Please check the box or boxes that apply: I request permission to inspect my original birth record 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 or 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, on which the names of my birth parents are stated. This information is necessary in order to assist me in establishing a legal right as set forth in the 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. Include a self-addressed stamped envelope if you wish to receive a copy of the final order, standard copy and certification charges will apply. Page 1 of 2 Form adopted for Mandatory Use Request Local Court Form Adopt-9 [Revised Sept. 2012] to Obtain Information from Original Birth Record-Adoptee Health & S. C. § 10275 www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com 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 * 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 Request Local Court Form Adopt-9 [Revised Sept. 2012] to Obtain Information from Original Birth Record-Adoptee Health & S. C. § 10275 www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com