Complaint,Petition: IN THE MATTER OF: OREN SIEGEL, ET AL.

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                  ATTORNEY OR PARTY WITHOUT ATTORNEY                          ,       ASTATE BAR NUMBER:                                                                                                  ‘

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                  ATTORNEY FOR (name). ..._—a-                                                                                                 SUP9”°' Coun 0!  a  I
                                                                                                                                                County of Los Ant-leies
                  SUPERIOR COURT OF CALIFORNIA. COUNTY OF                         -
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                          PETlTION FOR CHANGE OF NAME, RECOGNITION OF CHANGE 0l-
                                   GENDER, AND ISSUANCE OF NEW BIRTH CERTIFICATE                                                                '   U     u            00                   ‘

                     Before you complete this petition, you should read the Instructions for Filing on the next page. You must answer all
                     questions and check all boxes that apply to you on this petition. You must file this petition in the superior court of the
                     county where the person whose name is to be changed resides.
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                     PetitiOner( resent name)'« 3'\4,{((Ga
                     and a resident of this county.
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                                                                                                                                                        is 18 years old or older


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          2.         Petitioner requests that the court decree that petitioner's nam is change                             in order to conform to petitioner's gender identity, to
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                     (proposedname).                        co n “of         (Q [H/lg /‘              giejg


          3.         Petitioner requests a decree recognizing that the petitioner's gender is changed to:
                     a.        D female.
                     b.          male.
                     c.        D nonbinary.
          4.         Petitioner requests that the court order that a new birth certicate be issued reecting the gender and name changes sought by
                     this petition.

          5.         Petitioner requests that the court issue an order directing any interested persons to le written objections to show cause why
                     the petition for change of name should not be granted.

          6.         Petitioner provides the following information in support of this petition:

                     a.           The declaration below.
                     b-f.      The information contained in the attachment (attach a completed copy of the attachment Name and Information About the
                               Person Whose Name Is to Be Changed (fomI NC-110)).

                                                                                                DECLARATION
              I (present name):                                                             declare under penalty of perjury under the laws of the state of California that the
              request for a change in gender to (check one)       Dfemale                             Emale            [::|nonbinary        is to conformy-legal gender tony.
              gender identity and is not for any fraudulent purpose.                                                                                ’n,nd\,/d1,‘/¢/ “lffdlr (

              Date:                   —        I                     ,

                    0/2/9 (Wen 3; 96/                                                                              >           4~
.‘;_I                                 (TYPE OR PRINT NAME OF PETITIONER)                                                                     (SIGNATURE OF PETITIONER)
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,.~ 1‘,                                                                                      (Instructions on next page)                                                                  Page 1 of 2
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