Download this form for Requesting a Confidential Intermediary in the State of California.
Text Version of the Form
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Request for Appointment of Clerk stamps date here when form is filed.
Use this form if you are seeking contact with your sibling who is not
currently a dependent of the court and one of you has been adopted. If your
sibling is currently a dependent of the court, you must follow the procedure
in Welfare and Institutions Code section 388(b) instead of using this form.
Before completing this form, you must ask for contact with your sibling from
the department or licensed adoption agency that joined in your adoption or
your sibling’s adoption. If you do not know the name of the department or
agency, ask the California Department of Social Services, Adoption Support Fill in court name and street address:
Unit, 916-651-8088. Superior Court of California, County of
After filling out this form, bring it and a blank copy of the proposed Order
(ADOPT-331) to the clerk of the court where the adoption was finalized.
After the court signs the order, a copy of this Request and the Order will be
forwarded to the California Department of Social Services or the adoption
agency, as designated by the court, and copies will be given to you. Clerk fills in case number when form is filed.
1 I am asking the court to appoint a confidential intermediary to help me
get contact information for my sibling.
a. My name:
b. My address:
c. My phone number:
2 a. The person helping me complete this request for the appointment of a confidential intermediary is:
My attorney (State Bar No. ) My guardian ad litem
(3) Phone number:
b. I do not have an attorney or guardian ad litem who is helping me complete this request for the appointment
of a confidential intermediary.
3 An attorney used to represent me.
a. Name of former attorney:
b. Address of attorney:
c. Phone number of attorney:
d. This attorney used to represent me because:
4 The department or the licensed adoption agency that joined in the adoption petition for:
a. Name of agency:
c. Phone number:
Judicial Council of California, www.courtinfo.ca.gov Request for Appointment of ADOPT-330, Page 1 of 2
New January 1, 2008, Mandatory Form
Code of Civil Procedure, § 373 Confidential Intermediary
Family Code, § 9205
Cal. Rules of Court, rule 5.410
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5 The sibling whom I would like to contact is:
a. My sibling’s name:
b. My sibling’s current address (if known):
c. My sibling is under the age of 18 years.
(1) My sibling currently lives with (name and relationship to my sibling, if known):
(1) My sibling used to live with (name and relationship to my sibling, if known):
6 My sibling was adopted in this county: Yes No Unknown
7 My sibling was previously a dependent of the court in this county: Yes No Unknown
8 The following are true (check all that apply):
a. I submitted a written California Department of Social Services waiver form AD 904A or AD 904B to
the agency listed in 4 before I completed this form.
b. The agency in 4 sent a letter to me stating that no waiver for my sibling is in its file.
A copy of the letter from the agency is attached to this request.
c. I am asking the court to appoint a confidential intermediary to help me get contact information for my sibling.
d. I am under the age of 18 years.
(1) My parent/guardian signed a consent giving me permission to contact my sibling: Yes No
(2) The court signed a consent giving me permission to contact my sibling: Yes No
e. My sibling is under the age of 18 years.
f. To the best of my knowledge, there is not now, and never has been, an order stating that I cannot have
contact with the sibling named in 5 .
9 Any other information that would be helpful to the court:
I declare under penalty of perjury under the laws of the State of California that the information in items 1 through 9,
and in all attachments, is true and correct, which means that if I lie on this form, I am committing a crime.
Type or print your name Sign your name
Person who helped the applicant complete the form:
Type or print name Signature
Attorney Guardian ad litem
New January 1, 2008 Request for Appointment of ADOPT-330, Page 2 of 2