IN THE CIRCUIT COURT OF THE IN AND FOR JUDICIAL CIRCUIT COUNTY, FLORIDA DIVISION In the Interest of (pseudonym or initials of minor) ) ) ) ) ) Case No. PETITION FOR JUDICIAL WAIVER OF PARENTAL NOTICE OF TERMINATION OF PREGNANCY I certify that the following information is true and correct: (1) The pseudonym or initials of the minor (is/are) of True Name and Pseudonym with the clerk. (2) The minor is years old. , and the minor has filed a Sworn Statement (3) The minor is pregnant and notice has not been waived. (4) The minor desires to terminate her pregnancy without notice to a parent or legal guardian for one or more of the following reasons: [check all that apply] a. The minor is sufficiently mature to decide whether to terminate her pregnancy, for the following reason(s): b. The minor is a victim of child abuse or sexual abuse by one or both of her parents or a guardian. c. Notification of a parent or guardian is not in the best interest of the minor, for the following reason(s): (5) The minor requests that the court enter an order authorizing her to consent to the performance or inducement of a termination of pregnancy without notification of a parent or guardian. (6) The minor requests the appointment of an attorney to represent her in this matter: [check one]: yes no (7) The minor elects the following method or methods for receiving notices of hearings or other court actions in this Petition for Judicial Waiver of Parental Notice of Termination of Pregnancy {8.987} , revision effective 10/20/11 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com case: Through a third party whose name is and whose address and phone number for purposes of notice is . The minor will contact the office of the clerk of court at the following phone number: . I understand that by signing this form I am swearing to or affirming the truthfulness of the claims made in this petition and that the punishment for knowingly making a false statement includes fines, imprisonment, or both. (You may sign a name other than your true name, such as Jane Doe or other pseudonym under which your petition is being filed.) Signature: ______________________________________ Date: ____________________ Petition for Judicial Waiver of Parental Notice of Termination of Pregnancy {8.987} , revision effective 10/20/11 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com