SUPERIOR COURT OF ARIZONA _________________ COUNTY IN THE MATTER OF: ) ) ___________________________, ) a minor ) [Use true name of petitioner] ) ) ___________________________________ ) CASE NO. _____________________ ORDER GRANTING PETITION A hearing was held on a Petition to Authorize Physician to Perform Abortion on this ___ day of __________, 20___. The petitioner was present. The record was kept by_____________. The name of the court reporter, if applicable, is _______________________________. The petitioner was sworn and testified. Based on the evidence presented, THE COURT FINDS AS FOLLOWS: 1. _______________was appointed by the court to act as a guardian ad litem for petitioner. 2. ____ The petitioner was represented by an attorney, _________________________, who was present at the hearing; OR ____ The petitioner was advised of her right to court-appointed counsel and has knowingly and intelligently waived her right to counsel. 3. ____ The petitioner is mature and capable of giving informed consent to the proposed abortion; OR ____ The petitioner is not mature, but it is in the petitioner’s best interests to have the proposed abortion without having to obtain consent from one of her parents or her guardian or conservator, based on the following factors: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 07.25.2012 American LegalNet, Inc. www.FormsWorkFlow.com Case No: _____________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ THE COURT CONCLUDES AND ORDERS: 1. The requirements of A.R.S. § 36-2152(B) have been met. 2. The petition is granted. A physician chosen by the petitioner is hereby authorized to perform an abortion for petitioner without having to obtain the consent of her parents, guardian, or conservator. 3. The clerk of the court shall provide petitioner or her attorney with a certified copy of this order forthwith at no cost. 4. No member of the public shall inspect or obtain access to copies of this order or any other documents or records relating to this matter without the consent of the petitioner. 5. The record and evidence in this matter shall remain sealed and confidential. 6. No minute entry shall be issued. DATE:___________ ___________________________________ Judge of the Superior Court 07.25.12 2 American LegalNet, Inc. www.FormsWorkFlow.com Case No: _____________________________ A copy hereof was hand-delivered/mailed to petitioner/petitioner’s attorney, this ___ day of _______, 20___. ____________________________ Mailed/hand-delivered to guardian ad litem on _______________, 20___. _____________________________ 07.25.12 3 American LegalNet, Inc. www.FormsWorkFlow.com