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

What Is Form BMD-003A?

This is a legal form that was released by the California Superior Court - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2018;
  • The latest edition provided by the California Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form BMD-003A by clicking the link below or browse more documents and templates provided by the California Superior Court.

ADVERTISEMENT
ADVERTISEMENT

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

Download PDF

Fill PDF online

Rate (4.6 / 5) 85 votes
BMD-003A
ATTORNEY OR PARTY WITHOUT ATTORNEY:
STATE BAR NUMBER:
FOR COURT USE ONLY
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 (name):
CASE NUMBER:
DECLARATION IN SUPPORT OF PETITION TO
HEARING DATE AND TIME:
DEPT.:
ESTABLISH FACT, TIME, AND PLACE OF DEATH
declares as follows:
(Name of declarant):
I make the statements in this declaration based on my personal knowledge or on the contents of the documents identified in item 5.
1.
(“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.
(Name 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.):
State or province:
Country:
c.
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.)
Page 1 of 2
DECLARATION IN SUPPORT OF PETITION TO
Form Adopted for Mandatory Use
Health & Safety Code, §§ 103450–103490
Judicial Council of California
www.courts.ca.gov
ESTABLISH FACT, TIME, AND PLACE OF DEATH
BMD-003A [Rev. September 1, 2018]
BMD-003A
ATTORNEY OR PARTY WITHOUT ATTORNEY:
STATE BAR NUMBER:
FOR COURT USE ONLY
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 (name):
CASE NUMBER:
DECLARATION IN SUPPORT OF PETITION TO
HEARING DATE AND TIME:
DEPT.:
ESTABLISH FACT, TIME, AND PLACE OF DEATH
declares as follows:
(Name of declarant):
I make the statements in this declaration based on my personal knowledge or on the contents of the documents identified in item 5.
1.
(“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.
(Name 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.):
State or province:
Country:
c.
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.)
Page 1 of 2
DECLARATION IN SUPPORT OF PETITION TO
Form Adopted for Mandatory Use
Health & Safety Code, §§ 103450–103490
Judicial Council of California
www.courts.ca.gov
ESTABLISH FACT, TIME, AND PLACE OF DEATH
BMD-003A [Rev. September 1, 2018]
BMD-003A
CASE NUMBER:
IN THE MATTER OF (name):
Attached are true and correct copies of the following documents (check each box that applies):
5.
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.
is not
is
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.)
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)
DECLARATION IN SUPPORT OF PETITION TO
Page 2 of 2
BMD-003A [Rev. September 1, 2018
ESTABLISH FACT, TIME, AND PLACE OF DEATH
For your protection and privacy, please press the Clear
Print this form
Save this form
Clear this form
This Form button after you have printed the form.
Page of 2