PETITION FOR JUDICIAL AUTHORIZATION OF ABORTION Case No. ........................................................... Commonwealth of Virginia Va. Code 247 16.1-241-W Hearing Date and Time ....................................... PLEASE NOTE: All papers and hearings in this matter are confidential. ............................................................................................................ Juvenile and Domestic Relations District Court In re a petitioner under eighteen years of age: .................................................................................................................................................................................... PETITIONER'S NAME ....................................................... CONTACT TELEPHONE NUMBER (OPTIONAL) .............................................. DATE OF BIRTH ............... AGE ............................................ I, the undersigned, request this court to authorize a physician to perform an abortion pursuant to Virginia Code 247 16.1-241(W). I verify that the information given above is correct, and that I have elected not to seek consent of an authorized person as defined in Virginia Code 247 16.1-241(W). ................................................................... DATE PETITIONER'S SIGNATURE Sworn/affirmed and signed before me on ....................... DATE [ ] CLERK [ ] DEPUTY CLERK [ ] INTAKE OFFICER [ ] NOTARY PUBLIC My commission expires: .................................................. Filed by: [ ] Petitioner with Intake Officer [ ] Counsel for Petitioner .................................................................................. SIGNATURE OF COUNSEL Date and Time Petition Filed: ................................................. [ ] CLERK [ ] DEPUTY CLERK [ ] INTAKE OFFICER HEARING DATE A hearing on this petition has been set for ...................................................................... , at ................... m., DATE TIME in the ......................................................................................................... Juvenile and Domestic Relations District Court .................................................................................................................................................................................. ADDRESS AND COURTROOM COURT TELEPHONE NUMBER ............................................................ DATE [ ] CLERK [ ] DEPUTY CLERK [ ] INTAKE OFFICER ACKNOWLEDGEMENT OF HEARING DATE AND TIME 1. I understand that a hearing on this petition has been scheduled as noted above. 2. I acknowledge that I have received a copy of this petition and notice of hearing in person on this date. I waive all other forms of notice for hearing on this date. ........................................................................ DATE PETITIONER'S SIGNATURE SIGNATURE OF COUNSEL FOR THE PETITIONER FORM DC-502A MASTER 07/12 1 2 3 4 5 5 5 6 7 8 9 11 12 13 14 15 16 17 18 19 20 American LegalNet, Inc. www.FormsWorkFlow.com Form DC-502(A) PETITION FOR JUDICIAL AUTHORIZATION Form DC-502(A) OF ABORTION DISTRICT COURT MANUAL FORMS VOLUME JULY 2012 Data Elements 1. Court case number. 2. Hearing date and time. 3. Court jurisdiction. 4. Petitioner's name. 5. Petitioner's current telephone number, date of birth, and age. Telephone number is clearly marked as an optional data field. A petitioner should not be required to complete this data field. 6. Date petition is signed by petitioner. 7. Petitioner's signature. 8. Date of affirmation. 9. Signature of person administrating oath. Notary public should show date commission expires. 10. Check appropriate box. If filed by an attorney for the petitioner, attorney's signature. 11. Date and time petition filed with clerk/intake officer. 12. Signature of clerk/intake officer. 13. Date and time of hearing on the petition. 14. Name of court that will hear the case. 15. Address and telephone number of court; and specific courtroom in which hearing will be held, if known at the time of the filing of the petition. 16. Date on which hearing date is set. 17. Signature of clerk/intake officer who tells petitioner of hearing date and time. 18. Date on which petitioner acknowledges receipt of a copy of the petition and of the notice of hearing. 19. Petitioner's signature. 20. Counsel's signature, if applicable. American LegalNet, Inc. www.FormsWorkFlow.com