FORM SUMMARY Name of Form: Order on Waiver of Parental Consent for Abortion Form Number: JC-1623 Statutory Reference: §48.375(7), Wisconsin Statutes Benchbook Reference: JV 15 Purpose of Form: This order is issued by the court following the necessary hearings, and constitutes the decision of the court. The court is required to make a finding whether the juvenile is mature and well-informed enough to make her own decision about an abortion. If the court finds she is not sufficiently mature or well-informed enough, the court must then make a "best interests" determination whether an abortion is in her best interests. Based on the appropriate findings, the court either grants or denies the petition. Who Completes it: The order is signed by the judge. Because of the time requirements inherent in these statutes, it is believed that it would be completed in court at the conclusion of the hearing by the judge checking the appropriate boxes and, if necessary, adding additional findings or conclusions in paragraph 5. Alternatively, the form may be prepared in advance by the petitioner and presented to the court for signing. Distribution of Form: The original is filed with the Clerk of Circuit Court. If the petition is granted, a certified copy of the order is to be personally served on her counsel, or the clergy-person who filed the petition on her behalf. The counsel or clergy- person is then to "hand-deliver" a certified copy of the court order to the person or agent of the clinic or facility which will perform the abortion. If the petition is denied, a copy is to be personally served on her counsel or the clergy-person. The form includes the language concerning her rights to appeal. Accompanying Forms: Generally none. 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. 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 Order on Waiver of Parental Consent for Abortion IN THE INTEREST OF Jane Doe, Case No. Date of Birth a person under the age of 18. THE COURT FINDS AND CONCLUDES THAT: 1. A petition has been filed to waive parental consent for an abortion. 2. A clergyperson has filed with the petition an affidavit under s.48.375(7)(bm), Wisconsin Statutes. 3. A hearing was held on the petition at which time evidence was heard relating to: • the emotional development, maturity, intellect and understanding of the minor; • the understanding of the minor about the nature of, possible consequences of, and alternatives to the intended abortion procedure; and • other evidence the court found useful in making the determination about waiver of parental consent, including the report of the guardian-ad-litem, if one was appointed. 4a. The minor is mature and well-informed enough to make the abortion decision on her own. 4b. The minor is not mature and well-informed enough to make the abortion decision on her own, in which case I further find that: The performance or inducement of the abortion is in the minor's best interest. The performance or inducement of the abortion is not in the minor's best interest. 5. Other findings or conclusions relevant to the order: THE COURT ORDERS THAT: 1a. The petition is granted. An abortion may be performed without parental consent. • A certified copy of this decision shall be personally served on the minor or her attorney, or the member of the clergy who filed the petition on her behalf. 1b. The petition is denied. An abortion may not be performed except as otherwise provided by law. • A copy of this decision shall be personally served on the minor or her attorney, or the member of the clergy who filed the petition on her behalf. • The minor is also notified that she has an immediate right to appeal this decision under s.809.105, Wisconsin Statutes. BY THE COURT: Signature of Circuit Court Judge Name Printed or Typed Date JC-1623, 05/00 Order on Waiver of Parental Consent for Abortion §48.375(7), 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