COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. District Court Denver Juvenile Court : Calendar No. __________________________________________County, Colorado Court Address: Plaintiff(s) : -againstIN THE MATTER OF THE PETITION OF: : ___________________________________ [Name of Minor] JUDICIAL SUBPOENA : : For a Waiver of Parental Notification Requirements Concerning an Abortion Defendant(s) : ...................................................... Attorney, if Minor Represented (Name and Address): COURT USE ONLY Case Number: THE PEOPLE OF THE STATE OF NEW YORK Phone Number: E-mail: Division Courtroom FAX Number: Atty. Reg. #: PETITION FOR WAIVER OF PARENTAL NOTIFICATION REQUIREMENTS OF §12-37.5-104, C.R.S. TO The Petitioner, a minor, states: GREETINGS: 1. I am ___ years old. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 2. I am approximately ____ weeks pregnant andat the to terminateCourt desire the pregnancy by abortion. , the Honorable located at County of to have the abortion without telling my parent(s), guardian or foster parent. 3. I want in room , on the day of , 20 , at o'clock in the noon, and at any recessed 4. I am am not married. or adjourned date, to testify and give evidence as a witness in this action on the part of the 5. I do do not financially support myself. 6. I live with my: Your parent(s) comply with this subpoena is punishable as a contempt of court and will make you liable to failure to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a guardian result of your failure to comply. foster parent(s) Witness, Honorable relative: ____________ (state relationship) Court in County, day of , 20 , one of the Justices of the other: ______________(state relationship) 7. I have have not been informed about the risks and consequences of having the abortion. 8. (Check one or both): (Attorney must sign above and type name below) I believe I am mature enough to decide on my own to have an abortion without telling my parent(s), guardian or foster parent. Attorney(s) for It would not be in my best interest to tell my parent(s), guardian or foster parent of the abortion. 9. The name, business address and telephone number of the clinic or doctor who would perform the abortion are (this information is optional if you want to have the court’s decision sent directly to the clinic or doctor): Office and P.O. Address _______________________________________________________________________________________ ______________________________________________________________________________________. 10. JDF 11 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: I ask the Court to appoint a lawyer to represent me at no cost to me. 09/03 PETITION FOR WAIVER OF PARENTAL NOTIFICATION REQUIREMENTS OF §12-37.5-104, C.R.S. Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. I have a lawyer and ask the Court to appoint that person to continue to represent me. My lawyer’s : Calendar No. name, business address, telephone and fax numbers are: ___________________________________ : _________________________________________________________________________________ JUDICIAL SUBPOENA Plaintiff(s) I do not want to be represented by a lawyer. -against- : 11. I understand that the court proceedings and my court file are confidential and cannot be disclosed to anyone, : including my parent(s), guardian or foster parent. : 12. The Court can let me know of any Court proceedings or decisions in the following way: Defendant(s) : Via . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fax:. #___________________________; Attn:_______________________________ Via Telephone: #____________________________; Attn:_______________________________ Via E-mail: ____________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK Via Beeper or Pager #______________________________________ TO Via First Class Mail: _________________________________________________________________ _________________________________________________________________________________ Via My Attorney GREETINGS: 13. I ask that the Court provide me with a certified copy of the court’s order in the following way (check one): WE COMMANDMail: _________________________________________________________________ YOU, that all business and excuses being laid aside, you and each of you attend before Via First Class , the Honorable at the Court _________________________________________________________________________________ located at County of in room Via My, Attorney on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Via the Court File for pickup by me or ___________________________ who has my permission to pick up the certified copy on my behalf from the court file at the courthouse 14. TheYour days and times for me to come to court are: best failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result_______________________________________________________________________________________ of your failure to comply. _______________________________________________________________________________________ Witness, Honorable , one of the Justices of the Court in County, the Court enter an order allowing me to have the abortion without telling my day of , 20 WHEREFORE, I request to parent(s), guardian or foster parent. Respectfully submitted this ____ day of ___________, 20___. (Attorney must sign above and type name below) _____________________________________ Attorney(s) for Minor Signature of _____________________________________ Signature of Attorney, if Petitioner is represented Office and P.O. Address JDF 11 09/03 PETITION FOR WAIVER OF PARENTAL NOTIFICATION REQUIREMENTS OF §12-37.5-104, C.R.S. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com