State of Minnesota District Court County Judicial District: Court File Number: Case Type: Parental Notification In the Matter of the Petition of: Name Petition for Physician’s Authorization Address Date of Birth Petitioner moves the court pursuant to Minn. Stat. §144.343, subd. 6(c)(i) for authorization to her physician to perform an abortion upon said petitioner without prior notification being required or given to petitioner’s parent(s), guardian, or custodian. Petitioner bases her motion on one of the following alternative grounds: 1. She is mature and capable of giving informed consent to the proposed abortion. 2. It is in her best interests for the physician to perform the proposed abortion upon petitioner without prior notification of parent(s), guardian, or conservator. Wherefore, Petitioner requests an order authorizing her physician to perform an abortion upon her at her request and without prior notification being required or given to her parent(s), guardian, or custodian. Dated: Attorney for Petitioner Address , petitioner, being first duly sworn on oath, states that she has read the foregoing petition subscribed by her, that she knows the contents thereof, and that the same is true to her best information and belief. Dated: Signature (Sign only in front of notary public or court administrator.) Sworn/affirmed before me this day of , . Notary Public \ Deputy Court Administrator JUV201 State ENG Rev 01/02-D www.courts.state.mn.us/forms Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com