JC-1621, 05/00 Affidavit of Clergyperson to Waiver Parental Consent for Abortion 24748.375(7)(bm), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF Jane Doe, Date of Birth ( a person under the age of 18 ) Affidavit of Clergyperson to Waive Parental Consent for Abortion Case No. UNDER OATH I STATE: 1. My name is . 2. My address is . 3. I am an ordained clergyperson for . 4. I have personally met with the minor who is the subject of the petition to waive parental consent. 5. I have explored with the minor the alternative choices available to her for managing the pregnancy, including: carrying the pregnancy to term and keeping the infant; carrying the pregnancy to term and placing the infant with a relative or with another family for adoption; or having an abortion. 6. I have discussed with the minor, the possibility of involving one of the following people in her decision-making concerning her pregnancy: one of her parents; her guardian or legal custodian, if one has been appointed; an adult member of her family (grandparent, aunt, uncle, sister, or brother), who is at least 25 years of age, or one of her foster parents, if she has been placed in a foster home, and her parent has signed a waiver granting the department, a county department under 24724746.215, 46.22, or 46.23, or the foster parent, the authority to consent to medical services or treatment on her behalf. 7. I have discussed with the minor, whether or not involvement of one of the persons named in item 6 above would be in her best interests. It is her opinion such involvement would not be in her best interests. Question 8 is optional: 8. I have the following impressions concerning the minor and this decision: (State any other facts that you believe may be relevant to the court concerning this decision.) State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Clergyperson American LegalNet, Inc. www.FormsWorkFlow.com