Form 157 Rev 3/19 1 of 2 The Family Court of the State of Delaware In and For New Castle Kent Sussex County AFFIDAVIT AND APPLICATION FOR WAIVER OF NOTICE OF ABORTION (Pursuant to 24 Del. C. 247 1784, to be ruled on by the Court within 5 calendar days) IN THE MATTER OF ) ) ) ) ) ) ) ) BORN BE IT REMEMBERED that on this day of , , A.D. before me, , personally appeare d who, being duly sworn or affirmed, did depose and say: (1) That the minor applicant resides at (2) That the Court may send its order to (3) L eave telephone messages for the applicant minor at (4) That the minor applicant is pregnant; (5) That the minor applicant desires to obtain an abortion; (6) That the minor applicant desires that the Court waive the notice requirement of 24 Del C. Section 1783; (7) That the minor applicant believes that she is mature and well-informed enough to make the abortion decision on her own and/or it would be in her best interest that a waiver of notice be granted because (state reasons why mature and well-informed enough and/or waiver of notice is in best interest based upon the applicant222s age and family circumstances and the long-term and short-term consequences to the applicant of termination or continuation of the pregnancy): Street Address P.O. Box Number City / State / Zip Code Street Address P.O. Box Number City / State / Zip Code American LegalNet, Inc. www.FormsWorkFlow.com Form 157 Rev 3/19 2 of 2 The minor applicant requests that this file be sealed pursuant to Fami ly Court Rules of Civil Procedure 90.2 . WHEREFORE, this minor applicant intends to submit this affidavit and application for waiver of notice of abortion to the Family Court, and prays that an order be issued waiving the notification requirement of 24 Del. C. Section 1783 as to the following person: Name of person to whom notice is to be waived Relationship (Parent, Grandparent Guardian) Sworn to subscribed before me this day of , Clerk of Court / Notary Public Date Date Minor Applicant/Affiant 226 Print Name Minor Applicant/Affiant 226 Signature American LegalNet, Inc. www.FormsWorkFlow.com