MELROSE DR., VISTA, CA PETITION OF: DECLARATION OF PHYSICIAN RE CHANGE OF GENDER CASE NUMBER I, , am a licensed physician in the state of . I attest that petitioner , whose medical record indicates a date of birth of , is a patient of mine for the purpose of gender transition. I attest the petitioner has undergone the clinically appropriate treatment for the purpose of gender transition to male female. Physician’s Medical License or Certificate Number: Physician’s Address: Physician’s Tel. No.: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date: Signature