JC-1620, 10/00 Petition to Waive Parental Consent for Abortion 24748.257, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF Jane Doe, Date of Birth (a person under the age of 18) Petition to Waiver Parental Consent for Abortion Case No. 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 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 24748.375(4), Wis. Stats. Note: If the petitioner is the minor child, she is to sign the petition Jane Doe . She should not sign her real name. Petitioner Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com