Declaration Of Physician-Attachment To Petition {NC-210 NC-310}

NC-210/NC-310 PETITION OF (Name): CASE NUMBER: Page ____ of ____ DECLARATION OF PHYSICIAN DOCUMENTING CHANGE OF GENDER THROUGH CLINICALLY APPROPRIATE TREATMENT UNDER HEALTH AND SAFETY CODE SECTIONS 103425 AND 103430 Attachment to Petition for Change of Name and Gender (form NC-200) or Petition for Change of Gender and Issuance of New Birth Certificate (form NC-300) I declare under penalty of perjury under the laws of the State of California that the information in the foregoing declaration is true and correct. Date: (TYPE OR PRINT NAME OF PHYSICIAN) (SIGNATURE OF PHYSICIAN) Page 1 of 1 Form Approved for Optional Use Judicial Council of California NC-210/NC-310 [Rev. January 1, 2012] DECLARATION OF PHYSICIAN--ATTACHMENT TO PETITION (Change of Name and Gender/Change of Gender) Health and Safety Code, §§ 103425, 103430, 103435, 103440 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com