SUPERIOR COURT OF ARIZONA _________________ COUNTY IN THE MATTER OF: ) ) ___________________________, ) a minor ) [Use fictitious name if petitioner ) has so requested] ) ___________________________________ ) CASE NO. _____________________ NOTICE OF APPEAL 1. I hereby appeal from the denial of my Petition to Authorize Physician to Perform Abortion issued on_______________ by Judge ______________________ of the _______________________ Superior Court. 2. __________________was appointed by the court to act as guardian ad litem for me. 3. I am aware that the Court will appoint an attorney to represent me, at no charge to me, if I so choose. 4. ____ I request that the Court appoint an attorney to represent me in this matter, free of charge; OR ____ I do not request a court-appointed attorney. I have personally chosen to represent myself, and not be represented by an attorney; OR ____ I am represented by an attorney, as follows: Name of attorney _____________________________________________ Address ____________________________________________________ Telephone number ____________________________________________ 5. I ____ will ____ will not appear at the appellate hearing ____ in person ____ by telephone. My telephone number is ____________________________. DATE: ______________________ ________________________________________ 07.20.11 American LegalNet, Inc. www.FormsWorkFlow.com (Petitioner’s signature, using true name OR fictitious name OR initials) 07.20.11 American LegalNet, Inc. www.FormsWorkFlow.com