Attorney or Party without attorney (Name and Address) Telephone No.: Attorney for: NAME OF COURT: SUPERIOR COURT OF CALIFORNIA, COUNTY OF SHASTA Mailing Address 1500 Court Street, Room 319 Street Address 1500 Court Street, Room 319 Redding, CA 96001 Branch Name: Redding IN THE MATTER OF THE ADOPTION OF: Case Number: PETITION FOR BIRTH RECORD INFORMATION A- 1. Petitioner's name: _______________________________________________ Telephone ____________________________ Petitioner's address: Street:____________________________________, City__________________, State____, Zip:______ 2. Child's adopted name:_________________________________________________________________________________ Date of birth: _________________ Age now:________ Place of birth:___________________________________________ 3. I am informed and believe that I was adopted by ___________________________________________________________ on or about (date) ____________ in the County of _____________, State of California. OR 4. I am informed that an adoption proceeding relating to (adoptee)_____________________________________________ was completed in the County of ____________, State of California, on or about (date) ________________________________ by adoptive petitioners ___________________________________________________. My relation to said persons is as follows: (state relation to adoptee and adoptive petitioners)_____________________________________________________ 5. I request permission to inspect (check one): a. The entire adoption file but NOT the birth parents' names b. The original birth record. c. Other: ________________________________________________________________________________________________ 6. Explain why you need to inspect the adoption file/birth record: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ If additional space is required, attach separate sheet. Family Code �9200(a) states that an adoption file cannot be viewed "...except in exceptional circumstances and for good cause approaching the necessitous...". Family Code �9200(b) "Upon written request of any party to the proceeding and upon the order of any judge of the superior court, the clerk of the court shall not provide any documents referred to in this section for inspection or copying to any other person, unless the name of the child's birth parents or any information tending to identify the child's birth parents is deleted from the documents or copies thereof." Health & Safety Code �102705 states that an adopted child's birth record can only be "...viewed for good and compelling cause...". WHEREFORE, I request an order of the Court as required by Family Code Section 9200 and/or Health and Safety Code Section 102705 with respect to the records relating to the above proceeding. Signed (Petitioner) ____________________________________________________ Form Approved for Optional Use Shasta County Superior Court LF-ADP-100 [rev Jan. 1, 2016] PETITION FOR BIRTH RECORD INFORMATION FC �9200;HS �102705 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION STATE OF CALIFORNIA COUNTY OF SHASTA ) ) ) ss. I am the petitioner in the above matter; I have read the foregoing petition and know the contents thereof; I declare that the same is true of my own knowledge, except as to those matters which are therein stated upon my information and belief, and as to those matters, I believe them to be true. I declare under penalty of perjury that the foregoing is true and correct. Dated this ____________ day of _____________________, 20____, at __________________________California. Signed _____________________________________________ APPLICABLE FOR 5a or 5c COURT ORDER The Court, having fully considered the verified petition orders the clerk to furnish Petitioner with a copy of the following documents, upon payment of any fees required by law: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Dated: ________________________ ________________________________________________________ Judge of the Superior Court ****************************************************************************************************** TO BE SENT TO SACRAMENTO ONLY IF 5b IS REQUESTED STATE DEPARTMENT OF SOCIAL SERVICES Adoptions Branch 744 P Street M/S 8-12-31 Sacramento, CA 95814 The original of the above petition was filed in the office of the undersigned on _____________________________________. Please comply with the provisions of Section 102705 of the Health and Safety Code. Executive Officer of the Superior Court of the State of California, County of Shasta Dated: ____________________________ By:__________________________________________, Deputy Clerk's notation: Copy transmitted to the State Department of Social Services on __________________________________. SUPERIOR COURT JUDGE: Attached hereto are the records received by the undersigned from the State Department of Social Services after transmission of a copy of the above-verified petition to said department. Executive Officer of the Superior Court of the State of California, County of Shasta Dated: ____________________________ By: ___________________________________________, Deputy ****************************************************************************************************** (APPLICABLE FOR 5b ONLY) AFTER THE COURT HAS REVIEWED SAID RECORDS RECEIVED FROM SOCIAL SERVICES COURT ORDER The Court, having reviewed all of the attached records received from the State Department of Social Services and the foregoing verified petition and finding that good and compelling cause exists, now makes the following order: The Bureau of Vital Statistics shall furnish Petitioner with a copy of the original birth record upon payment for the fees required by law. Dated: __________________________ _______________________________________________________ Judge of the Superior Court Form Approved for Optional Use Shasta County Superior Court LF-ADP-100 [rev Jan. 1, 2016] PETITION FOR BIRTH RECORD INFORMATION FC �9200;HS �102705 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com