AOC-260 Rev. 4-01 Page 1 of 2 Doc. Code: PAB Case No. Court County ABORTION PETITION Commonwealth of Kentucky Court of Justice KRS 311.732 IN RE: SELF-CONSENT FOR AN ABORTION BY A MINOR NOTICE TO PETITIONER: The Clerk will assist you in preparing and filing this Petition if necessary. Anonymity of the Petitioner is required by KRS 311.732. Comes the Petitioner, ________, a minor under the age of 18, (check one) (initials) by herself; by counsel; or by her next friend _____________________________________________________________, (Name) and in support of this Petition for an order of self-consent for an abortion by a minor states that the minor is pregnant and (check all that apply): The minor is mature and well-informed enough to make the abortion decision on her own; Performance of the abortion is in the minor's best interest. WHEREFORE, Petitioner prays for the Court to set a hearing within 72 hours of the filing of this Petition, inclusive of weekends and holidays; appoint a guardian ad litem; and appoint counsel; OR proceed without payment of fees because the minor has insufficient funds to pursue this procedure. Initials of Petitioner (address where Petitioner can be reached) (telephone number for Petitioner) (2nd address where Petitioner can be reached) (2nd telephone number for Petitioner) Signature of Petitioner's Next Friend: Signature of Petitioner's Counsel: Date Petition Filed: ____________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ____________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ___________________ ____________________________________________________________ ____________________________________________________________ __________________, 2______ American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 AOC-260 Rev. 4-01 Page 2 of 2 Pursuant to special rules of the Kentucky Supreme Court, this Petition and all information relating thereto shall be confidential; shall not be a public record; and shall not be released to the public. To be completed by clerk: NOTICE TO PETITIONER: A hearing on this matter has been set for _________________, 2_____, at _______ a.m. / p.m. which is within 72 hours (inclusive of weekends and holidays) from the filing of the Petition. You must attend. It will occur at: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________ has been appointed as your guardian ad litem. ______________________________________________________ has been appointed as your counsel (if requested). Should this Court fail to render a decision within 72 hours (inclusive of weekends and holidays) from the filing of this Petition, you may take an immediate appeal to the Kentucky Court of Appeals. Should this Court fail to render a decision immediately following the hearing, you are responsible for contacting the clerk of the trial court for notification of the Judge's decision. The 72-hour time period may be extended by you. Distribution: Petitioner Guardian ad litem Counsel American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2