(SC-AD-2) SUPPORTING DECLARATION RE ADOPTION RECORDS SISKIYOU COUNTY LOCAL COURT RULE 14.11C Name:_______________________________ Address:____________________________ ____________________________________ Telephone:__________________________ SUPERIOR COURT OF CALIFORNIA FOR THE COUNTY OF SISKIYOU ) ) ) _________________________________________,) (Name ) __________________________________________) In the Matter of the Adoption of CASE NO.______________ PPORTING DECLARATION RE ADOPTION RECORDS I, the undersigned ________________________________, declare as follows: (Print Name) 1. I am the ______________________________________________________________________ in this matter. (Relationship to Parties to Adoption, If Any, e.g., Adoptee) 2. On _________________________________, a decree of adoption was entered in this matter, decreeing ______________________________________ to be the adopted child of______________________________________________________________________. (Name/s of Adoptive Parent/s) (Name) (Date) 3. Medical necessity or other extraordinary circumstances, explained below, justify the disclosure of records relating to the aforesaid adoption [IF MORE SPACE IS REQUIRED, PLEASE ATTACH ADDITIONAL PAGES.]: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that this declaration was executed on _______________________________ at _______________________________________________. (Date) (Place) Signature:____________________________________ Printed Name:_________________________________ PAGE 1 OF 1 American LegalNet, Inc. www.FormsWorkFlow.com