(TYPE OR PRINT IN BLACK INK) File No. STATE OF NORTH CAROLINA In The General Court Of Justice County District Court Division IN THE MATTER OF: Name And Address Of Juvenile JUVENILE PETITION FOR Date Of Birth Age Social Security Number EMANCIPATION State And County Of Birth G.S. 7B-3500 et. seq. Being sixteen (16) years of age or older and having resided in the above county in North Carolina, or on federal territory within the boundaries of North Carolina, for six months next preceding the filing of this Petition, I petition the Court for a judicial decree of emancipation and respectfully show the following. 1. A certified copy of my birth certificate is attached. 2. The name(s) and last known address(es) of my parent(s), guardian, or custodian are: 3. My address and length of residence at that address are: 4. I request emancipation for the following reasons: AOC-J-900M, Rev. 7/2000 2000 Administrative Office of the Courts (Over) >>>> 2 5. My plan for meeting my own needs and living expenses is stated below: (You may attach a statement of employment and wages earned which is verified by your employer.) I request: 1. That the Court issue an order declaring me to be emancipated. 2. Such other and further relief as to the Court may deem just. VERIFICATION Being first duly sworn, I say that I have read this Petition and that the same is true to my own knowledge, except as to those matters alleged upon information and belief, and as to those, I believe it to be true. Date SWORN AND SUBSCRIBED TO BEFORE ME Date Signature Of Person Authorized To Administer OathsSignature Of Juvenile Name Of Juvenile (Type Or Print) Deputy CSC Assistant CSC Clerk Of Superior Court Date My Commission Expires SEAL Notary (A certified copy of the birth certificate of the petitioner must be attached.) AOC-J-900M, Side Two, Rev. 7/2000 2000 Administrative Office of the Courts