FORM SUMMARY Name of Form: Petition to Waive Parental Consent for Abortion Form Number: JC-1620 Statutory Reference: §48.257, Wisconsin Statutes Benchbook Reference: JV 15 Purpose of Form: This form initiates a juvenile court proceeding, in which a juvenile is seeking judicial consent to waive the requirement for parental consent to have an abortion. Who Completes it: This form may be filed by either the juvenile herself, in which case she signs the petition as "Jane Doe," or a member of the clergy who files it on her behalf. There is no filing fee. Distribution of Form: The original is filed with the Clerk of Circuit Court. If the juvenile files the petition, a copy is provided to her. If a member of the clergy files the petition, a copy is given to the clergyperson and a copy is served on the juvenile. Accompanying Forms: If a member of the clergy files the petition, the clergy- person must also file an "Affidavit of Clergyperson to Waive Consent for Abortion," (JC1621), with the petition. 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 5/00. Modifications: Corrected spelling of word “Consent” in title of form. Comments: 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. Update: 10/20/00 American LegalNet, Inc. www.FormsWorkflow.com For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Petition to Waive Parental Consent for Abortion IN THE INEREST OF Jane Doe, Case No. Date of Birth a person under the age of 18. I state that: 1a. I am a pregnant minor seeking the waiver of parental consent for an abortion. 1b. I am a clergy person seeking the waiver of parental consent for an abortion on behalf of a pregnant minor. Notice of hearings should be provided to me by: personal service at telephone at . . 2. The pregnant minor is represented by attorney at . is not represented by an attorney at this time. Notice of hearings should be provided to her by: personal service at . telephone at . 3. The date of birth of this minor is given above. 4. The estimated gestational age of the fetus at this time is weeks (or) months. 5. This minor is seeking an abortion and has been fully informed of (a) the risks and consequences of abortion; and (b) the risks and consequences of carrying the pregnancy to term. 6. The person, clinic, or medical facility that will perform or induce the abortion is: not known at this time. Name: Address: 7. This minor is mature and well-informed enough to make her own decision on whether or not to have an abortion because: (State facts sufficient to establish the minor's level of maturity and information). 8. If the circuit court does not find this minor mature enough and well-informed enough to make her own decision on whether or not to have an abortion, I ask that the circuit court find that having an abortion is in the minor's best interests because: (State facts sufficient to establish that an abortion is in this minor's best interests.) I request that the court: 1. Set a date and time for a hearing. 2. Order counsel appointed. 3. Approve this petition and order waiver of the parental consent requirement under s.48.375(4), Wisconsin Statutes. Signature of Petitioner Note: If the petitioner is the minor child, she is to sign the petition Jane Doe. She should not sign her real name. Name Printed or Typed Date JC-1620, 10/00 Petition to Waive Parental Consent for Abortion; §48.257, 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