1 2 3 4 5 In the Matter of: IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF MARION Juvenile Department ) ) ) ) Case No. APPLICATION FOR JUDGMENT OF EMANCIPATION Interpreter needed. Language: , and I am now years of age. , in the city of , County of Marion, Oregon, and I intend that Marion County be my place of residence for the indefinite future. 3) My custodial parent(s) or guardian(s) do do not consent to my emancipation. 4) I am substantially able to be self-sufficient and self-supporting without parental guidance and supervision. 5) I am sufficiently mature and knowledgeable to manage my own affairs without parental assistance. 1) Declaring me to be an emancipated minor. 2) Advising me of my civil and criminal rights and liabilities; and 3) Instructing me to obtain from the Oregon Motor Division an Oregon driver's license or identification card with a notation thereon of my emancipated status. Parent and/or Guardian Information: Parent and/or Guardian Information: Parent and/or Guardian's Name Relation to Applicant Mailing Address , Applicant Name. 6 The Applicant states as follows: 7 8 9 10 11 12 13 1) I was born on the 2) I currently reside at day of 14 WHEREFORE, I request that the Court enter a Judgment as follows: 15 16 17 18 19 20 Parent and/or Guardian's Name 21 Relation to Applicant 22 Mailing Address 23 24 25 City, State, Zip Code City, State, Zip Code ( ) ( ) Phone Number Phone Number A separate sheet is attached to list additional parents and/or guardians. SUBSCRIBED and SWORN before me this day of , 20 . 26 Applicant Information: 27 Applicant Signature 28 Mailing Address City, State, Zip ( ) Phone Number Emancipation Application Page 1 of 1 Notary Public for the State of Oregon/Court Clerk My Commission Expires: FC (6/20/13)