CONFIDENTIAL STATE OF NORTH CAROLINA County Name Of Minor File No. IN THE MATTER OF: In The General Court Of Justice District Court Division PETITION FOR WAIVER OF PARENTAL CONSENT FOR MINOR'S ABORTION G.S. 90-21.6 through -21.10; 7A-451(a)(16), 7B-200 Date Of Birth Age PETITION The minor named above asks the Court for a waiver of the parental consent requirement for an abortion. The minor is under 18 years of age, has not been married and has not been emancipated by a court. The minor is pregnant and resides or is physically present in this county. At least one of the following conditions applies: None of the persons who could give consent is available to give consent; or The person who could give consent refuses to give consent; or The minor does not want to seek consent from any of those persons. The minor The minor does does does not want the Court to appoint an attorney to represent her in this proceeding. does not want her parent, legal guardian, or custodian to receive notice of this proceeding. (If the minor does want her parent, legal guardian, or custodian to receive notice, give the name, address, and telephone number.) The minor understands that court papers will be sent to the attorney and/or guardian ad litem who represents her (if applicable). The minor requests that notice of hearing or other information and documents also be sent to: (a) (b) Date the minor at the following address: Other: (name and address) Signature Minor Attorney Guardian ad Litem NOTE: I have received a copy of the written "Instructions For Minor Petitioner", AOC-J-601 Instructions. ORDER APPOINTING ATTORNEY The attorney named below is appointed to represent the minor in this proceeding. Name, Address And Telephone No. Of Attorney Date Signature Assistant CSC District Court Judge Clerk Of Superior Court Superior Court Judge NOTICE OF HEARING A hearing on the above Petition will be held on the date and at the time and location specified below. Date Of Hearing Location Of Hearing Time Of Hearing Date AM PM Signature Deputy CSC Assistant CSC Clerk Of Superior Court filing the petition and shall ensure that the minor's identity is kept confidential. (1) Do not calendar or take minutes of this proceeding. This proceeding is completely confidential. (2) Do not serve a copy of the petition, notice, or other papers on the minor's parents, legal guardian, or custodian unless the minor so requests in the petition. (3) The minor is not required to pay any court costs. No judgment for attorney fees or guardian ad litem fees should be entered. (4) This matter must be given precedence over other pending matters to ensure that the court reaches a decision promptly - at least within 7 days of the filing of the petition. (Over) NOTE TO CLERK: Pursuant to G.S. 90-21.8(b), the Court shall ensure that the minor or her guardian ad litem is given assistance in preparing and AOC-J-601, Rev. 6/12 © 2012 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE This certifies that on this date I served the Notice Of Hearing: on the minor by: personally delivering a copy to her. mailing a copy to the address listed on the reverse. telephoning her at the following number on the attorney for the minor by: personal delivery. mailing a copy to the address listed on the reverse. telephoning the attorney at the number listed on the reverse. on the guardian ad litem for the minor by: personal delivery. mailing a copy to the address listed on the Order Of Appointment. telephoning the guardian ad litem at the number listed in the Order Of Appointment. on the person listed below, at the request of the minor by: personal delivery. mailing a copy to the address listed below. telephoning the person at the following number Name Of Person To Whom Notice Delivered Or Mailed Address To Which Notice Mailed Date Notice Served Signature . . Deputy CSC Assistant CSC Clerk Of Superior Court REQUEST TO EXTEND TIME FOR HEARING The minor petitioner requests that the time for the hearing on her petition be extended. Date Of Request Signature Minor Attorney Guardian Ad Litem ORDER EXTENDING TIME FOR HEARING At the request of the minor petitioner for an extension of time, the hearing on the petition in this proceeding will be held at the date, time and location specified below. New Date Of Hearing Location Of Hearing New Time Of Hearing Date Of Order AM PM Signature Deputy CSC Assistant CSC Clerk Of Superior Court AOC-J-601, Side Two, Rev. 6/12 © 2012 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com