BMD-003A - Declaration in Support of Petition to Establish Fact, Date, and Place of Death

Summary

Declaration in Support of Petition to Establish Fact, Date, and Place of Death

Text

Form ID: BMD-003A
Title: Declaration in Support of Petition to Establish Fact, Date, and Place of Death
Effective Date: 2018-09-01
Mandatory Form: yes
Info Page: https://selfhelp.courts.ca.gov/jcc-form/BMD-003A
Primary Download URL: https://www.courts.ca.gov/documents/bmd003a.pdf
Form Detail Page:
Declaration in Support of Petition to Establish Fact, Date, and Place of Death
(BMD-003A)
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 Death. This is always attached to form BMD-003.
Get form BMD-003A
Effective: September 1, 2018
PDF Text:
Page 1 of 2
Form Adopted for Mandatory Use 
Judicial Council of California 
BMD-003A [Rev. September 1, 2018]
DECLARATION IN SUPPORT OF PETITION TO 
ESTABLISH FACT, TIME, AND PLACE OF DEATH
Health & Safety Code, §§ 103450–103490 
www.courts.ca.gov
BMD-003A
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
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
IN THE MATTER OF (names):
DECLARATION IN SUPPORT OF PETITION  
TO ESTABLISH FACT, TIME, AND PLACE OF DEATH
(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.   (Names of deceased person): died at
approximately (time): 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 died 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-003A [Rev. September 1, 2018 DECLARATION IN SUPPORT OF PETITION TO 
ESTABLISH FACT, TIME, AND PLACE OF DEATH
Page 2 of 2
BMD-003A
CASE NUMBER:IN THE MATTER OF (name):
5. Attached are true and correct copies of the following documents (check each box that applies):
a.  Police report dated (date of each):
b. Coroner's report dated (date):
c. Private physician's report 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.
6. The death of the person named in item 3, or the date, time, or place of death                                            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.
7. Number of pages attached:
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)

Retrieval chunks

• #1

  Form ID: BMD-003A Title: Declaration in Support of Petition to Establish Fact, Date, and Place of Death Effective Date: 2018-09-01 Mandatory Form: yes Info Page: https://selfhelp.courts.ca.gov/jcc-form/BMD-003A Primary Download URL: https://www.courts.ca.gov/documents/bmd003a.pdf Form Detail Page: Declaration i…

• #2

  BMD-003A [Rev. September 1, 2018 DECLARATION IN SUPPORT OF PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH Page 2 of 2 BMD-003A CASE NUMBER:IN THE MATTER OF (name): 5. Attached are true and correct copies of the following documents (check each box that applies): a. Police report dated (date of each): b. C…