Rule 8.34 -- Form 1 February 2002 IN THE IOWA DISTRICT COURT FOR ________________________ COUNTY (JUVENILE DIVISION) IN THE INTEREST OF ____________________________________, A Minor. Juvenile No. _______________________ PETITION FOR WAIVER OF PARENTAL NOTIFICATION OF MINOR'S ABORTION PURSUANT TO IOWA CODE SECTION 135L.3 I, the above-named minor, state: 1. I am under 18 years of age. 2. I am approximately _________ weeks pregnant and seek an abortion by a licensed physician, without notification of a parent. 3. (Check one) _____ a. I am accompanied by a responsible adult (a responsible adult is a person who is 18 or over and who is not associated with the clinic or physician who will perform the abortion). _____ b. 4. I am not accompanied by a responsible adult. (Check one) I have viewed the video prepared by the Iowa Department of Public Health that explains my options as a pregnant minor, including parenting, adoption, and abortion. I have not viewed the video. _____ a. _____ b. 5. (Check one) I understand that I have the right to a court-appointed attorney at no cost to me. Please appoint an attorney to represent me. I have an attorney to represent me. The attorney's name, address, and telephone number is ___________ _________________________________________________________________________________. _____ a. b. 6. I understand that this proceeding will be kept secret from my parents and the public. The only persons who may attend any hearing on the petition are myself, my attorney, my guardian ad litem (if one is appointed) and those whose presence I, my attorney, or my guardian ad litem specifically request. I request that the following person(s) be notified of and admitted to all hearings in my case: Name(s) and address(es): ________________________________________________________________________ _____________________________________________________________________________________________. 7. I understand court personnel will not send any papers to my home or try to call me. I would like to be informed of the court's decision in the following way: _____________________________________________________________ _____________________________________________________________________________________________. I request the following person(s), in addition to my attorney, be contacted and given papers in my case: Name(s) and address(es): ________________________________________________________________________ _____________________________________________________________________________________________. American LegalNet, Inc. www.FormsWorkflow.com 8. (Check one or both) I am mature and capable of providing informed consent for the performance of an abortion. It would not be in my best interests to notify a parent of my abortion for the following reasons: __________________________________________________________________________________ __________________________________________________________________________________ _________________________________________________________________________________. _____ a. _____ b. 9. I state on oath that (check one) I am presenting this request to a court for the first time. I have made this request to a court before and was refused. _____ a. _____ b. 10. The name, business address, and business telephone number (if these are known) of the physician who will perform the abortion is ______________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________. THEREFORE, I request that the court grant my application to obtain an abortion without notifying a parent. Signed on this _____________________ day of _______________________, 20 _____. __________________________________________________ Petitioner (You may sign a name other than your true name, such as Jane Doe) American LegalNet, Inc. www.FormsWorkflow.com