PETITION (Parental Notification) In the Juvenile Court of __________________________ County, Georgia CASE NUMBER_____________________ In the Interest of SEX _______________________________ ______________________________ DOB _______________ AGE ___________ An Unemancipated Minor To the Juvenile Court of ______________________ County, Georgia: 1. Your petitioner alleges that the court has jurisdiction in that the minor is under the age of 18 and 2. That the within petition is filed in the best interest of the said minor, and 3. Said minor states that she desires to have her pregnancy terminated by approved medical procedures and asks that the court waive the requirements of O.C.G.A. 15-11-112 and asks the court to consider her request under the provisions of O.C.G.A. 15-11-114. A statement from a licensed medical doctor confirming the pregnancy and current trimester of gestation is attached and made a part of this petition by reference, and 4. Said minor further alleges: ________ that she is mature and sufficiently well-informed to make an intelligent decision on her own concerning an abortion; or ________ that notice to a parent or guardian pursuant to O.C.G.A. 15-11-112 would not be in her best interest, particulars being: Therefore, petitioner prays for relief under the provisions of Article 3 of the Official Code of Georgia, Chapter 11 of Title 15. ______________________________ (Petitioner: Minor/Next Friend) Subscribed and sworn to before me this _____ day of _________________________, 20____. ______________________________ (Attesting Officer) Rev. 01/2001 JUV-18>>>> 2 Notice of Hearing Petition having been filed in this court, a hearing is hereby scheduled to determine the merits of the petition on the ______ day of _____________________, 20_____ at _________________ at the ______________ Juvenile Court, located at _______________________________________. Notice of Right to Counsel Said minor is hereby notified that she has a right to court appointed counsel and that the court will provide such minor with counsel upon request or if such minor is not already adequately represented. Pursuant to the above, the undersigned minor hereby requests that the court appoint legal counsel to represent her in this matter. _________________________________ (Minor) Waiver of Counsel I, the aforementioned minor, having been explained my right to counsel, hereby waive that right and elect to proceed without benefit of legal counsel. _________________________________ (Minor) Appointment of Guardian Ad Litem Pursuant to Rule 23.2 of the Uniform Rules for Juvenile Courts, the Court hereby appoints ________________________ as guardian ad litem to protect the interests of the minor. This __________ day of ____________________________, 20____. _________________________________ Judge or Court Designee Rev. 01/2001 JUV-18