_______________________________ Name _______________________________ Address (optional) _______________________________ City (optional) _______________________________ Telephone (optional) _____________________________________________________________________________ IN THE ________________DISTRICT JUVENILE COURT FOR_________________COUNTY ______________________________________________________________________________ IN THE INTEREST OF_________________, ) PETITION FOR WAIVER OF A MINOR. ) PARENTAL CONSENT TO ) MINOR'S ABORTION PURSUANT JUVENILE NO._____________________ ) TO UTAH CODE SECTION 76-7-304.5 ) ______________________________________________________________________________ I, the above-named minor, state: 1. I am under 18 years of age and not married or emancipated. My birthdate
is:________________. 2. 3. I am a resident of ________________________. I am approximately _______weeks pregnant and seek an abortion by a licensed
physician, without consent from a parent or guardian. 4. I understand that I have the right to a court-appointed attorney and/or guardian ad
litem at no cost to me. (Check One) _____a. me. Please appoint an attorney and/or a guardian ad litem to represent
I have an attorney to represent me. The attorney's name, address,
and telephone number is________________________________________________________. _____c. 5. I do not want an attorney or guardian ad litem.
I understand that the court will not notify my parents, the father, or any member
of the public. The only persons who may attend any hearing on the petition are court personnel, myself, my attorney, my guardian ad litem and those whose presence I specifically request. I request that the following person(s) be admitted to all hearings in my case: Name(s) and address(es)__________________________________________________________ ______________________________________________________________________________ 6. I understand that court personnel will not send any papers to or try to call me at
my home without my consent. I would like to be informed of the court's decision in the following way (list address, cell phone number, e-mail address, fax number, or other): _________________________________________________________________ I request the following person(s), in addition to my attorney and/or guardian ad litem, be contacted and given papers in my case: Name(s) and address(es)__________________________________________________________ ______________________________________________________________________________ 7. (Check one or both) I have given my written informed consent to the abortion and I am mature
and capable of giving informed consent for the performance of an abortion. A copy of my 2
written consent is attached. _____b. An abortion is in my best interest for the following reasons:
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 8. I state that (check one) I am presenting this request to a court for the first time. I have made this request to a court before and was denied. The judge on
that case was: ___________________________________. 9. The name, business address, and business telephone number (if these are known)
of the physician who will perform the abortion is:______________________________________ ______________________________________________________________________________ THEREFORE, I request that the court grant my Petition for Waiver of Parental Consent to a Minor's Abortion. Signed on this______day of_____, 20______.