STATE OF MAINE DISTRICT COURT Location Docket No. In re: Petitioner REQUEST FOR ASSIGNMENT OF COUNSEL FOR EMANCIPATION PETITION 15 M.R.S. § 3506-A(1) I, age (must be at least 16 years of age). My date of birth is The names and addresses of my parents, guardians or custodians are: Name Address Name Address , am years of . Relationship Telephone Relationship Telephone I desire to petition this court for an order of emancipation. I request this court to assign an attorney to petition for my emancipation. Date: Petitioner Address Telephone ********************************************************************************************** ORDER The court assigns to represent the Petitioner named above in an emancipation proceeding pursuant to 15 M.R.S. § 3506-A. Counsel shall file a Petition for Emancipation within thirty days of receiving notice of this assignment, or the matter is subject to dismissal without further notice to counsel or the juvenile and without prejudice. See Administrative Order JB-05-19. Date: FM-065, Rev. 04/14 Page 1 of 1 Judge American LegalNet, Inc. www.FormsWorkFlow.com