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DECLARATION IN SUPPORT OF PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH Form Adopted for Mandatory Use Judicial Council of California BMD-003A [Rev. September 1, 2018] Health & Safety Code, §§ 103450–103490 www.courts.ca.govPage 1 of 2 SUPERIOR COURT OF CALIFORNIA, COUNTY OF BRANCH NAME: CITY AND ZIP CODE: STREET ADDRESS: MAILING ADDRESS: IN THE MATTER OF (name): FOR COURT USE ONLY CASE NUMBER: DECLARATION IN SUPPORT OF PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH BMD-003A ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE: ZIP CODE: CITY: STREET ADDRESS: FIRM NAME: NAME: TELEPHONE NO.: FAX NO.: E-MAIL ADDRESS: ATTORNEY FOR ( name): STATE BAR NUMBER: HEARING DATE AND TIME: DEPT.: Facts showing when and where the person named in item 3 died and explaining how I have personal knowledge of those facts 1. 3. 2. 4. I am at least 18 years of age. a. b. 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.) declares as follows: died at at the following place: (Name of declarant): I reside at (street address and city): County: State: (Name of deceased person): approximately (time): on (date): (If you are relying solely on the contents of the documents identified in item 5, please advise in the space below.) b. c. City, town, township, or other (identify “other” if known): County: State (U.S.): State or province: Country: a. a.m. p.m. are stated in Attachment 4 to this declaration. are stated in the space below 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.) (SIGNATURE OF DECLARANT) BMD-003A [Rev. September 1, 2018 Page 2 of 2 DECLARATION IN SUPPORT OF PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH Date: (TYPE OR PRINT NAME OF DECLARANT) BMD-003A CASE NUMBER: IN THE MATTER OF (name): I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. 5. 6. 7. a. c. b. d. (date of each): (date): (date of each): (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): Number of pages attached: Attached are true and correct copies of the following documents (check each box that applies): Police report dated Private physician's report dated Coroner's report dated Other documents dated Continued on Attachment 5d. Continued on Attachment 6. is not is Print this form Save this form Clear this form For your protection and privacy, please press the Clear This Form button after you have printed the form.