FORM SUMMARY Name of Form: Affidavit of Clergyperson to Waive Parental Consent for Abortion Form Number: JC-1621 Statutory Reference: §48.375(7)(bm), Wisconsin Statutes Benchbook Reference: JV 15 Purpose of Form: A member of the clergy may file a "Petition to Waive Parental Consent for an Abortion," (JC-1620), on behalf of a pregnant juvenile. The clergyperson must accompany the petition with an affidavit stating that certain statutory requirements have been complied with. Items 1 through 7 are required by statute. However, since the court may base its ultimate decision solely on the basis of the affidavit, item 8 was added as an optional question to provide additional information to the court. Who Completes it: The clergyperson who files the affidavit must complete it and have it notarized. Distribution: The original is filed with the Clerk of Circuit Court along with the petition. A copy is provided to the clergyperson and a copy is served on the juvenile. Accompanying Forms: This form must accompany the "Petition to Waive Parental Consent for an Abortion," (JC-1610), when a member of the clergy is filing the petition. It is not required when a pregnant juvenile is filing the petition on her own behalf. A juvenile who wants 24 hours notice of hearings, rather than immediate notice, may also have completed the "Waiver of Immediate Notice (Parental Consent/Abortion Waivers)," (JC-1622). If so, that form may be attached. New Form/Modification: Modification, last update 7/96. Modifications: Added a file/date stamp to upper right corner. Added a statement on the bottom indicating that the form shall not be modified. Comments: None. About this form: This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office and a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. Date: 05/31/00 American LegalNet, Inc. www.FormsWorkflow.com For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Affidavit of Clergyperson to Waive Parental Consent for Abortion IN THE INTEREST OF Jane Doe, Case No. Date of Birth a person under the age of 18. Under oath I state that: 1. My name is . 2. My address is . 3. I am an ordained clergyperson for . 4. I have personally met with the minor who is the subject of the petition to waive parental consent. 5. I have explored with the minor the alternative choices available to her for managing the pregnancy, including: • carrying the pregnancy to term and keeping the infant; • carrying the pregnancy to term and placing the infant with a relative or with another family for adoption; or • having an abortion. 6. I have discussed with the minor, the possibility of involving one of the following people in her decision-making concerning her pregnancy: • one of her parents; • her guardian or legal custodian, if one has been appointed; • an adult member of her family (grandparent, aunt, uncle, sister, or brother), who is at least 25 years of age, or • one of her fosterparents, if she has been placed in a foster home, and her parent has signed a waiver granting the department, a county department under §§46.215, 46.22, or 46.23, or the foster parent, the authority to consent to medical services or treatment on her behalf. 7. I have discussed with the minor, whether or not involvement of one of the persons named in item 6 above would be in her best interests. It is her opinion such involvement would not be in her best interests. Question 8 is optional: 8. I have the following impressions concerning the minor and this decision: (State any other facts that you believe may be relevant to the court concerning this decision.) Subscribed and sworn to before me on Signature of Clergyperson Notary Public, State of Wisconsin My commission expires: JC-1621, 05/00 Affidavit of Clergyperson to Waive Parental Consent for Abortion §48.375(7)(bm), Wisconsin Statutes. This form shall not be modified. It may be supplemented with additional material. Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com