Name, Address of Petitioner or Attorney Telephone No. PETITIONER SUPERIOR COURT OF CALIFORNIA, COUNTY OF STANISLAUS Street Address: City and State and Zip Code: In the Matter of the Petition of: PETITION FOR BIRTH RECORD INFORMATION (California Health and Safety Code 102705) CASE NUMBER: THIS FORM IS TO BE USED TO PETITION THE COURT TO INSPECT OR COPY ADOPTION RECORDS MAINTAINED BY THE STATE DEPARTMENT OF SOCIAL SERVICES. DO NOT USE IF YOUR ADOPTION WAS A STEPPARENT ADOPTION. Name: __________________________________________________________________________________ My Permanent Residence Address is _____________________________________________________ in the County of __________________________________, State of _____________________________________. I was born on _____________________________________________ and am now __________ years of age. I am informed and believe that I was adopted by _____________________________________________ and __________________________________, on or about ________________________________, in the County of ___________________________, State of California. OR I am informed that an adoption proceeding relating to _______________________________ was completed in Sonoma County, State of California on or about ________________________________________________, by __________________________________________ and ___________________________________________, adoptive petitioners. My relation to said persons is as follows (please state relation to adoptee and adoptive petitioners): _______________________________________________________________________________ _________________________________________________________________________________________. Form Number: FL-094 Effective Date: 6/25/13 PETITION FOR BIRTH RECORD INFORMATION Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com I request permission to inspect the records and/or obtain copies of records relating to the birth of the named person. The facts that make such an order necessary are: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ I specifically request to be allowed to inspect the following adoption records: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Pursuant to Health and Safety Code section 102705, I request the release of records relating to the above proceedings. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct to be best of my knowledge and belief. DATED: _______________________ _______________________________________ Petitioner's Signature Form Number: FL-094 Effective Date: 6/25/13 PETITION FOR BIRTH RECORD INFORMATION Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com