IMPOUNDED PETITION (Pursuant to G.L. c. 112, 247 12S) DOCKET NUMBERCASE NAME: Trial Court of MassachusettsThe Superior Court COURT NAME & ADDRESS IN THE MATTER OF MARY MOE AOSC 6/2019 CountyClerk of CourtsMARY MOEDated 1. This action is brought pursuant to G.L. c. 112, 247 12S. By this action, the plaintiff, a woman under the age of eighteen (18) years, seeks an order of the Court permitting her to obtain an abortion without parental consent. The plaintiff has decided not to seek the consent of a parent or guardian. 2. The plaintiff is 4. years of age and is not married. The plaintiff's parent or guardian has refused to consent to the performance of an abortion. WHEREFORE, the plaintiff requests: [cross out any that do not apply] 1. That this Court enter an Order authorizing a physician to perform an abortion on plaintiff without parental consent. 2. That these papers be IMPOUNDED, to protect the privacy of the plaintiff. 3. That this Court waive payment of all fees and costs by plaintiff. 4. That this Court appoint an attorney to represent the plaintiff at the expense of the Commonwealth. PLEASE SIGN "MARY MOE" AND SIGN THE CONFIDENTIAL AFFIDAVIT PROVIDED BY THE CLERK USING YOUR OWN NAME. 3. The plaintiff believes that she is approximately weeks pregnant. The plaintiff is unable to pay the fees and costs of this proceeding. 5. American LegalNet, Inc. www.FormsWorkFlow.com