State of Alabama Unified Judicial System Form JU-26 Case Number PETITION FOR WAIVER OF CONSENT FOR ABORTION Rev. 1/09 IN THE JUVENILE COURT OF _____________________________________________________COUNTY, ALABAMA (Name of County) In the Matter of __________, a minor (Initials Only) Comes now the petitioner and shows unto the court as follows: 1. I am _____________ years of age. Date of Birth:_________________. 2. I am a legal resident of _____________________________(Town/City), ___________________(Country) _________________________________(State). The abortion procedure will be performed in __________________________________County, Alabama. 3. I am approximately ___________ days ___________ weeks ______________ months pregnant. 4. I am unmarried, unemancipated and under 18 years of age. 5. I wish to have an abortion performed without the consent of either parent or legal guardian. 6. CHECK ONE OR BOTH OF THE FOLLOWING STATEMENTS AS THEY APPLY TO YOUR CASE. I am sufficiently mature and well enough informed to intelligently decide to have an abortion without the consent of either parent or legal guardian. ____ One or both of my parents or my legal guardian has engaged in a pattern of physical, sexual, or emotional abuse against me, or the consent of my parents, parent, or legal guardian otherwise is not in my best interests. 7. ____ I have retained ___________________________________________________ as my attorney. My attorney’s address is ________________________________________________________________________________ _________________________________________. Telephone Number: _____________________. I hereby 8. request waive appointment of counsel by the court. I have not previously filed, nor do I have pending, any other petition seeking a waiver of consent for an abortion of my present pregnancy. __________________________________ Date ______________________________________________ Initials of Minor Petitioner or Signature of Attorney Sworn to and Subscribed before me this the __________ day of _______________________, __________ ______________________________________________ Intake Officer/Clerk/Notary Public It is hereby ORDERED that this Petition for Waiver of Consent be set down for a hearing and the minor petitioner appear in court On (Date) ________________________________________ at ________ o’clock ___ M. at ________________________ ____________________________________________________________________ . ______________________________________ Date ______________________________________________ Judge Ala. Code 1975, §26-21-4(d) American LegalNet, Inc. www.FormsWorkFlow.com