BMD-001A - Declaration in Support of Petition to Establish Fact, Time, and Place of Birth

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Declaration in Support of Petition to Establish Fact, Time, and Place of Birth

Text

Form ID: BMD-001A
Title: Declaration in Support of Petition to Establish Fact, Time, and Place of Birth
Effective Date: 2018-09-01
Mandatory Form: yes
Info Page: https://selfhelp.courts.ca.gov/jcc-form/BMD-001A
Primary Download URL: https://www.courts.ca.gov/documents/bmd001a.pdf
Form Detail Page:
Declaration in Support of Petition to Establish Fact, Time, and Place of Birth
(BMD-001A)
Make a declaration (a statement in writing that you swear under penalty of perjury is true) to the court about the facts that support your Petition to Establish Fact, Time, and Place of Birth. This is always attached to form BMD-001.
Get form BMD-001A
Effective: September 1, 2018
PDF Text:
Page 1 of 2
Form Adopted for Mandatory Use 
Judicial Council of California 
BMD-001A [Rev. September 1, 2018]
DECLARATION IN SUPPORT OF PETITION TO 
ESTABLISH FACT, TIME, AND PLACE OF BIRTH
Health & Safety Code, §§ 103450–103490 
www.courts.ca.gov
BMD-001A
FOR COURT USE ONLY
CASE NUMBER:
HEARING DATE AND TIME: DEPT.:
ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER:
NAME:
FIRM NAME:
STREET ADDRESS:
CITY: STATE: ZIP CODE:
TELEPHONE NO.: FAX NO.:
E-MAIL ADDRESS:
ATTORNEY FOR (name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
BRANCH NAME:
CITY AND ZIP CODE:
STREET ADDRESS:
MAILING ADDRESS:
IN THE MATTER OF (name):
DECLARATION IN SUPPORT OF PETITION TO 
ESTABLISH FACT, TIME, AND PLACE OF BIRTH
(Name of declarant): declares as follows:
1.    I make the statements in this declaration based on my personal knowledge or on the contents of the documents identified in item 5. 
(“Personal knowledge” of a fact is knowledge that is not gained from another person's statements to you about that fact.)
2.  a. I am at least 18 years of age.
b. I reside at (street address and city):
County: State: 
3.   (Name): was born at
approximately (time of birth): a.m. p.m.  on (date):  at the following place:
a. City, town, township, or other (identify “other” if known):
b. County:  State (U.S.): 
c. State or province: Country:
4.  Facts showing when and where the person named in item 3 was born and explaining how I have personal knowledge of those facts 
are stated in the space below  are stated in Attachment 4 to this declaration. 
(If you are relying solely on the contents of the documents identified in item 5, please advise in the space below.)

For your protection and privacy, please press the Clear 
button after you have printed the form.
BMD-001A [Rev. September 1, 2018 DECLARATION IN SUPPORT OF PETITION TO 
ESTABLISH FACT, TIME, AND PLACE OF BIRTH
Page 2 of 2
BMD-001A
CASE NUMBER:IN THE MATTER OF (name):
6. The birth of the person named in item 3, or the date, time, or place of birth                                            important to a court case or 
proceeding that is now pending and described below. (If you selected “is,” briefly describe the proceeding and provide the case 
name and number, the name and address of the court where the proceeding is pending, the names of all parties to the proceeding, 
and the names, addresses, and telephone numbers of their attorneys. Note: A court order made on a petition under Health and 
Safety Code section 103450, et seq., may not be effective against claims of persons or organizations not given notice of 
the petition for the order.)
is not is
Continued on Attachment 6.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME  OF DECLARANT)
 (SIGNATURE OF DECLARANT)
5. Attached are true and correct copies of the following documents (check each box that applies; statements of witnesses must 
be signed under oath, in an affidavit sworn before a Notary Public or with the following statement just above the signature: “I 
declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct”):
a.  Hospital records dated (date of each):
b.  Physician's report dated (date of each):
c.   Witness statements dated (date of each):
d. Other documents dated (describe and give the date of each document; “Other documents” could include school or 
college records, vaccination certificates and other medical records, employment records, documents showing sources of 
support other than employment, family correspondence, diaries, photographs, and other similar family records):
Continued on Attachment 5d.
7. Number of pages attached:

Retrieval chunks

• #1

  Form ID: BMD-001A Title: Declaration in Support of Petition to Establish Fact, Time, and Place of Birth Effective Date: 2018-09-01 Mandatory Form: yes Info Page: https://selfhelp.courts.ca.gov/jcc-form/BMD-001A Primary Download URL: https://www.courts.ca.gov/documents/bmd001a.pdf Form Detail Page: Declaration i…

• #2

  BMD-001A [Rev. September 1, 2018 DECLARATION IN SUPPORT OF PETITION TO ESTABLISH FACT, TIME, AND PLACE OF BIRTH Page 2 of 2 BMD-001A CASE NUMBER:IN THE MATTER OF (name): 6. The birth of the person named in item 3, or the date, time, or place of birth important to a court…