Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY CONFIDENTIAL INFORMATION FOR PROCEEDINGS CONCERNING WAIVER OF PARENTAL CONSENT FILE NO. In the matter of the petition of Initials , a minor, for waiver of parental consent for an abortion Certain information about you is being requested by the court for two reasons: 1. In case the court needs to contact you while this proceeding is pending. 2. To identify who you are in a court order if your petition for waiver of parental consent is granted. · This information is strictly confidential and will be kept by the court in a sealed envelope marked confidential in a private file. It is available only to the judge, specifically authorized court personnel, yourself, your attorney, and anyone else you authorize. · If the court grants your petition, your name and date of birth will be stated in the order. However, an order granting your petition will also be kept in the sealed envelope marked confidential. · If the court denies your petition and you appeal the court's order, your entire file (including the sealed envelope containing this information) will be provided to the Court of Appeals. Please print in the boxes provided below the following information: 1. Your full name. 2. Your date of birth. 3. Your permanent residence (address, city, zip). 4. The initials you will be using in the title of this proceeding; for example, "In the matter of the petition of 5. How the court or your attorney can get in contact with you; for example, a telephone number. , a minor." Minor's full name Date of birth Initials used in title Permanent residence Means of contact I declare that this confidential information is true to the best of my information, knowledge, and belief. Date Signature of minor Do not write below this line - For court use only MCR 3.615 PC 122 (9/10) CONFIDENTIAL INFORMATION FOR PROCEEDINGS CONCERNING WAIVER OF PARENTAL CONSENT American LegalNet, Inc. www.FormsWorkFlow.com