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Here is the text we could read:

ATTORNEY OR PARTY WITHOUT ATTORNEY:

STATE BAR NUMBER:

BMD-001A

FOR COURT USE ONLY

NAME:

FIRM NAME:

STREET ADDRESS:

CITY:

TELEPHONE 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 (name):

STATE:

FAX NO.:

ZIP CODE:

CASE NUMBER:

DECLARATION IN SUPPORT OF PETITION TO
ESTABLISH FACT, TIME, AND PLACE OF BIRTH

HEARING DATE AND TIME:

DEPT.:

(Name of declarant):

declares as follows:

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.)

a.
b.

I am at least 18 years of age.
I reside at (street address and city):

County:

(Name):

City, town, township, or other (identify “other” if known):

County:

State or province:

State:

was born at

State (U.S.):

Country:

approximately (time of birth):

a.m.

p.m.

on (date):

at the following place:

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.)

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

Page 1 of 2

Health & Safety Code, §§ 103450–103490
www.courts.ca.gov

IN THE MATTER OF (name):

CASE NUMBER:

BMD-001A

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”):

Hospital records dated

(date of each):

Physician's report dated

(date of each):

Witness statements dated

(date of each):

Other documents dated
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):

(describe and give the date of each document; “Other documents” could include school or

Continued on Attachment 5d.

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

Continued on Attachment 6.

Number of pages attached:

Date:

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

(TYPE OR PRINT NAME OF DECLARANT)

(SIGNATURE OF DECLARANT)

BMD-001A [Rev. September 1, 2018

Page 2 of 2

DECLARATION IN SUPPORT OF PETITION TO
ESTABLISH FACT, TIME, AND PLACE OF BIRTH

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

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 2
Fields(s): 58
Average fields per page: 29
Reading Level: Grade 8
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

page_caption_sf_crt_county_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].CourtInfo[0].CrtCounty_ft[0] (0.62 conf)
bm_page_p_caption_sf_court_info_branch_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].CourtInfo[0].Branch_ft[0] (0.39 conf)
bm_page_p_caption_sf_court_info_city_zip_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].CourtInfo[0].CityZip_ft[0] (0.37 conf)
bm_page_p_caption_sf_court_info_street_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].CourtInfo[0].Street_ft[0] (0.33 conf)
bm_page_p_caption_sf_court_info_mailing_add_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].CourtInfo[0].MailingAdd_ft[0] (0.43 conf)
bm_page_p_caption_sf_title_party_name_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].TitlePartyName[0].Party1_ft[0] (0.35 conf)
page_p_caption_sf_number_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].CaseNumber[0].CaseNumber_ft[0] (0.36 conf)
bm_page_p_caption_sf_atty_info_state_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyState_ft[0] (0.39 conf)
bm_page_p_caption_sf_atty_info_zip_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyZip_ft[0] (0.36 conf)
bm_page_p_caption_sf_atty_info_city_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyCity_ft[0] (0.40 conf)
bm_page_p_caption_sf_atty_info_street_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyStreet_ft[0] (0.42 conf)
bm_page_p_caption_sf_atty_info_firm_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyFirm_ft[0] (0.43 conf)
bm_page_p_caption_sf_atty_info_name_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyName_ft[0] (0.39 conf)
bm_page_p_caption_sf_atty_info_bar_dc was BMD-001A[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyBarNo_dc[0] (0.36 conf)
bm_page_p_caption_sf_atty_info_phone_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].AttyInfo[0].Phone_ft[0] (0.34 conf)
bm_page_p_caption_sf_atty_info_fax_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].AttyInfo[0].Fax_ft[0] (0.36 conf)
bm_page_p_caption_sf_atty_info_email_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].AttyInfo[0].Email_ft[0] (0.39 conf)
bm_page_p_caption_sf_atty_info_ft was BMD-001A[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyFor_ft[0] (0.39 conf)
page_p_sf_hearing_time_ime__1 was BMD-001A[0].Page1[0].p1Caption_sf[0].HearingDateTime_sf[0].HearingDateTIme_ft[0] (0.46 conf)
page_p_sf_hearing_time_ime__2 was BMD-001A[0].Page1[0].p1Caption_sf[0].HearingDateTime_sf[1].HearingDateTIme_ft[0] (0.46 conf)
bm_page_declarant_name was BMD-001A[0].Page1[0].declarant\.name[0] (0.34 conf)
bm_page_b_declarant_address was BMD-001A[0].Page1[0]._02\.b\.declarant\.address[0] (0.33 conf)
bm_page_b_declarant_county was BMD-001A[0].Page1[0]._02\.b\.declarant\.county[0] (0.33 conf)
bm_page_b_declarant_state was BMD-001A[0].Page1[0]._02\.b\.declarant\.state[0] (0.33 conf)
bm_page_name was BMD-001A[0].Page1[0]._03\.name[0] (0.33 conf)
bm_page_time_birth was BMD-001A[0].Page1[0]._03\.time\.of\.birth[0] (0.33 conf)
bm_page_date_birth was BMD-001A[0].Page1[0]._03\.date\.of\.birth[0] (0.33 conf)
bm_page_facts was BMD-001A[0].Page1[0]._04\.facts[0] (0.33 conf)
bm_page_place_birth_city_ft was BMD-001A[0].Page1[0].PlaceOfBirthCity_ft[0] (0.37 conf)
bm_page_place_birth_county_ft was BMD-001A[0].Page1[0].PlaceOfBirthCounty_ft[0] (0.39 conf)
bm_page_place_birth_u_state_ft was BMD-001A[0].Page1[0].PlaceOfBirthUState_ft[0] (0.40 conf)
bm_page_place_birth_state_u_ft was BMD-001A[0].Page1[0].PlaceOfBirthStateNotUS_ft[0] (0.41 conf)
bm_page_place_birth_country_u_ft was BMD-001A[0].Page1[0].PlaceOfBirthCountryNotUS_ft[0] (0.41 conf)
bm_page_checkbox__1 was BMD-001A[0].Page1[0].Checkbox[0] (0.33 conf)
bm_page_checkbox__2 was BMD-001A[0].Page1[0].Checkbox[1] (0.33 conf)
bm_page_b_time_choice_cb__1 was BMD-001A[0].Page1[0].ToBTimeChoice_cb[0] (0.35 conf)
bm_page_b_time_choice_cb__2 was BMD-001A[0].Page1[0].ToBTimeChoice_cb[1] (0.35 conf)
bm_page_facts_cb__1 was BMD-001A[0].Page1[0].Facts_where_cb[0] (0.34 conf)
bm_page_facts_cb__2 was BMD-001A[0].Page1[0].Facts_where_cb[1] (0.34 conf)
bm_page_birth_fact_important_desc_ft was BMD-001A[0].Page2[0].BirthFactImportantDesc_ft[0] (0.39 conf)
bm_page_fill_text__1 was BMD-001A[0].Page2[0].FillText1140[0] (0.39 conf)
bm_page_fill_text__2 was BMD-001A[0].Page2[0].FillText56[0] (0.39 conf)
bm_page_px_caption_sf_case_number was BMD-001A[0].Page2[0].PxCaption_sf[0].CaseNumber[0].CaseNumber[0] (0.33 conf)
bm_page_px_caption_sf_title_party_name_ft was BMD-001A[0].Page2[0].PxCaption_sf[0].TitlePartyName[0].Party1_ft[0] (0.34 conf)
page_hospital_record_dates_ft was BMD-001A[0].Page2[0].HospitalRecordDates_ft[0] (0.30 conf)
page_physicians_record_dates_ft was BMD-001A[0].Page2[0].PhysiciansRecordDates_ft[0] (0.36 conf)
page_witness_statement_date_ft was BMD-001A[0].Page2[0].WitnessStatementDate_ft[0] (0.39 conf)
bm_page_docs_desc_date_ft was BMD-001A[0].Page2[0].OtherDocsDescDate_ft[0] (0.39 conf)
bm_page_pages_attached_ft was BMD-001A[0].Page2[0].PagesAttached_ft[0] (0.33 conf)
bm_page_documents_attached_cb was BMD-001A[0].Page2[0].DocumentsAttached_cb[0] (0.37 conf)
bm_page_hospital_records_cb was BMD-001A[0].Page2[0].HospitalRecords_cb[0] (0.29 conf)
bm_page_physician_records_cb was BMD-001A[0].Page2[0].PhysicianRecords_cb[0] (0.37 conf)
bm_page_witness_statement_cb was BMD-001A[0].Page2[0].WitnessStatement_cb[0] (0.30 conf)
bm_page_documents_cb was BMD-001A[0].Page2[0].OtherDocuments_cb[0] (0.39 conf)
bm_page_att_documents_f_cb was BMD-001A[0].Page2[0].AttDocuments_OF_cb[0] (0.38 conf)
bm_page_desc_importance_f_cb was BMD-001A[0].Page2[0].DescImportance_OF_cb[0] (0.33 conf)
bm_page_birth_facts_important_cb__1 was BMD-001A[0].Page2[0].BirthFactsImportant_cb[0] (0.32 conf)
bm_page_birth_facts_important_cb__2 was BMD-001A[0].Page2[0].BirthFactsImportant_cb[1] (0.32 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

page_caption_sf_crt_county_ft
bm_page_p_caption_sf_court_info_branch_ft
bm_page_p_caption_sf_court_info_city_zip_ft
bm_page_p_caption_sf_court_info_street_ft
bm_page_p_caption_sf_court_info_mailing_add_ft
bm_page_p_caption_sf_title_party_name_ft
page_p_caption_sf_number_ft
bm_page_name
bm_page_px_caption_sf_case_number
bm_page_px_caption_sf_title_party_name_ft
bm_page_docs_desc_date_ft
bm_page_pages_attached_ft

Suggested Screen 1:

bm_page_p_caption_sf_atty_info_state_ft
bm_page_p_caption_sf_atty_info_zip_ft
bm_page_p_caption_sf_atty_info_city_ft
bm_page_p_caption_sf_atty_info_street_ft
bm_page_p_caption_sf_atty_info_firm_ft
bm_page_p_caption_sf_atty_info_name_ft
bm_page_p_caption_sf_atty_info_bar_dc
bm_page_p_caption_sf_atty_info_phone_ft
bm_page_p_caption_sf_atty_info_fax_ft
bm_page_p_caption_sf_atty_info_email_ft
bm_page_p_caption_sf_atty_info_ft

Suggested Screen 2:

page_p_sf_hearing_time_ime__1
page_p_sf_hearing_time_ime__2

Suggested Screen 3:

bm_page_declarant_name
bm_page_b_declarant_address
bm_page_b_declarant_county
bm_page_b_declarant_state

Suggested Screen 4:

bm_page_place_birth_city_ft
bm_page_place_birth_county_ft
bm_page_place_birth_u_state_ft
bm_page_place_birth_state_u_ft
bm_page_place_birth_country_u_ft

Suggested Screen 5:

bm_page_checkbox__1
bm_page_checkbox__2

Suggested Screen 6:

bm_page_facts
bm_page_b_time_choice_cb__1
bm_page_b_time_choice_cb__2
bm_page_facts_cb__1
bm_page_facts_cb__2
bm_page_fill_text__1
bm_page_fill_text__2
bm_page_hospital_records_cb
bm_page_physician_records_cb
bm_page_witness_statement_cb
bm_page_desc_importance_f_cb

Suggested Screen 7:

page_hospital_record_dates_ft
page_physicians_record_dates_ft
page_witness_statement_date_ft

Suggested Screen 8:

bm_page_documents_attached_cb
bm_page_documents_cb
bm_page_att_documents_f_cb

Suggested Screen 9:

bm_page_time_birth
bm_page_date_birth
bm_page_birth_fact_important_desc_ft
bm_page_birth_facts_important_cb__1
bm_page_birth_facts_important_cb__2

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

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

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02