SDSC JUV-249 (New 9/12) DECLARATION OF BIRTH MOTHER ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FAX NO.(Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, JUVENILE COURT, 2851 MEADOW LARK DR., SAN DIEGO, CA NORTH COUNTY DIVISION, 325 S.

MELROSE DR., SUITE 130,VISTA, CA IN THE MATTER OF THE PETITION OF DECLARATION OF BIRTH MOTHER CASE NUMBER I, __________________________________________________, declare the following: I am the biological mother of ____________________________, born on ____________ in _______________________. I was married to _____________________________________ on __________________ in ______________________. A dissolution of this marriage was final on or about _______________. I have not cohabited with _______________ since ________________________________________.

It is physically impossible for _______________________________ to be the father of ___________________________. 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 Signature of Birth Mother