Approved, SCAO Distribution: Original - Circuit court 1st copy - Minor (Notice of appeal to circuit court) 2nd copy - Minor (Claim of appeal to Court of Appeals) 3rd copy - Minor (Claim of appeal to circuit court) 4th copy - Minor STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY APPEAL OF ORDER DENYING PETITION FOR WAIVER OF PARENTAL CONSENT FILE NO. In the matter of the petition of Initials , a minor, for waiver of parental consent for an abortion NOTICE OF RIGHT TO TIMELY APPEAL 1. An order denying your petition for waiver of parental consent to an abortion was issued by the family division of this court on at Date Time . A copy of the order is attached. 2. You have a right to appeal to the Court of Appeals this order denying your petition. 3. If you want to appeal, you must complete the notice of appeal at the bottom of this form and file it in the family division of this circuit court within 24 hours of the date and time stated in item 1 above. 4. If you file the notice of appeal on time, an attorney will be appointed to represent you or you may hire your own attorney. 5. Bring all four copies of this form with you when you file. After you file the notice of appeal, the court will return three copies of this form to you for use by you and your attorney in claiming your appeal. 6. Within 72 hours (excluding Sundays and holidays) after filing the notice of appeal on time, your attorney must file with the Court of Appeals the claim of appeal on the other side of this notice along with a copy of the order appealed from. A copy of the claim of appeal must also be filed with the family division of this circuit court. See MCR 3.615 for details for perfecting an appeal and filing the brief on appeal. RECEIPT OF NOTICE On this day I read this form or had it read to me, and I received four copies of it. I understand that if I want to appeal the order denying my petition for waiver of parental consent, I must complete and file the notice of appeal with the family division of this circuit court within 24 hours of the date of the order. Date Time Initials of minor/Signature of next friend Name of next friend (type or print) NOTICE OF APPEAL TO THE CIRCUIT COURT: The minor appeals the order denying waiver of parental consent for an abortion and requests the court to appoint an attorney to appeal the order. Date Time Initials of minor/Signature of next friend Name of next friend (type or print) See other side for Order for Court-Appointed Attorney and Claim of Appeal. Do not write below this line - For court use only NOTICE OF APPEAL FILED ON: Date Time I certify that the Notice of Appeal was was not filed within 24 hours of the date of the order denying the petition. Deputy clerk PC 121 (9/10) APPEAL OF ORDER DENYING PETITION FOR WAIVER OF PARENTAL CONSENT MCL 722.904, MCR 3.615 American LegalNet, Inc. www.FormsWorkFlow.com APPEAL OF ORDER DENYING PETITION FOR WAIVER OF PARENTAL CONSENT File No. ORDER FOR COURT-APPOINTED ATTORNEY AND PREPARATION OF TRANSCRIPT IT IS ORDERED: 1. Name of attorney (type or print) Address City, state, zip Telephone no. Bar no. is appointed attorney to represent the minor on her appeal of the order denying her petition for waiver of parental consent. The appeal shall be perfected within 72 hours of the filing of the notice of appeal. 2. The court reporter/recorder shall immediately prepare the transcript of the proceedings and file two copies with the family division of the circuit court within 72 hours from the date of this order. 3. Upon filing of the transcript, the court clerk shall notify the attorney that the transcript is available and shall immediately forward the file, including one copy of the transcript, to the Court of Appeals. Date Judge Bar no. CLAIM OF APPEAL TO THE COURT OF APPEALS: In the matter of the petition of Initials , a minor, for waiver of parental consent for an abortion 1. The petitioner claims an appeal from the order denying waiver of parental consent for an abortion (copy attached) which was entered on Date in the . Bar no. County Circuit Court, Michigan by Judge 2. The brief on appeal is attached. Date Attorney signature Name of attorney (type or print) Address City, state, zip Telephone no. Bar no. American LegalNet, Inc. www.FormsWorkFlow.com