Declaration Of Physician Documenting Gender Change

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NC-210/NC-310
CASE NUMBER:
PETITION OF (Name):
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
Health and Safety Code, §§ 103425, 103430,
DECLARATION OF PHYSICIAN—ATTACHMENT TO PETITION
Judicial Council of California
103435, 103440
(Change of Name and Gender/Change of Gender)
NC-210/NC-310 [Rev. January 1, 2012]
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