Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION FILE NO. PETITION FOR WAIVER OF PARENTAL CONSENT FOR AN ABORTION COUNTY In the matter of the petition of Initials , a minor, for waiver of parental consent for an abortion next friend of the minor. 1. I am the minor. 2. The minor resides or is found in this county. 3. The minor is pregnant, wants an abortion, and desires to give her own consent to the abortion. 4. The minor requests an order waiving parental consent for the abortion because the minor's parent or legal guardian is not available or refuses to give his or her consent, or the minor has elected not to seek consent of her parent or legal guardian. 5. As next friend, I certify that I am an adult and none of the following: a. a physician who performs abortions. b. a person who is employed by, or receives financial consideration from, a physician who performs abortions or an organization that provides abortions or abortion counseling and referral services. c. a person who serves as a board member or volunteer to an organization that provides abortions or abortion counseling and referral services. I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Attorney signature Name (type or print) Address City, state, zip Telephone no. Bar no. Initials of minor/Signature of next friend Name of next friend (type or print) Address of next friend City, state, zip Telephone no. Do not write below this line - For court use only PC 119 (9/10) PETITION FOR WAIVER OF PARENTAL CONSENT FOR AN ABORTION MCL 722.904, MCR 3.615 American LegalNet, Inc. www.FormsWorkFlow.com