Confidential Verification
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Confidential Verification Form. This is a Pennsylvania form and can be use in Orphans Court Statewide.
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Tags: Confidential Verification, ACA-02, Pennsylvania Statewide, Orphans Court
CONFIDENTIAL VERIFICATION
COURT OF COMMON PLEAS OF
COUNTY, PENNSYLVANIA
(JUVENILE COURT SECTION OF THE FAMILY DIVISION)
“ ORPHANS’ OR “ FAMILY COURT DIVISION
IN RE: Matter of
, A Minor
:
Application No.
:
of 2
(Initials)
1.
I,
(initials only), am the applicant in a separate application for an abortion under
Section 3206 of the Abortion Control Act, 18 Pa.C.S. § 3206.
2.
The name and address of each of my parents, guardian or person standing in loco parentis
is as follows (please print):
Father:
Name
Street
City, State, Zip
Mother:
Name
Street
City, State, Zip
Guardian:
Name
Street
City, State, Zip
Form ACA-02 rev. 10.13.06
Page 1 of 2
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IN RE: Matter of
, A Minor
(Initials)
3.
I verify that the statements made in the separate application and in this unsworn
verification are true and correct to the best of my personal knowledge or information and
belief.
I understand that false statements herein are made subject to penalties of Section 4904 of
the Crimes Code, 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.
Applicant’s Signature
(Initials may be used as signature)
Applicant’s Date of Birth
Date
Form ACA-02 rev. 10.13.06
Page 2 of 2
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