Free STATE OF SOUTH CAROLINA - South Carolina

STATE OF SOUTH CAROLINA COUNTY OF

IN RE: JANE DOE, a Minor Under the Age of Seventeen (17) years

) ) ) ) ) ) ) ) )

IN THE [ ] FAMILY COURT IN THE [ ] COURT OF COMMON PLEAS JUDICIAL CIRCUIT FILE NO: DECLARATION OF MINOR UNDER THE AGE OF SEVENTEEN (17) YEARS

NOTICE TO THE CLERK OF COURT: A CERTIFIED COPY OF THIS DECLARATION, WITH THE FILE NUMBER NOTED ON IT, SHOULD BE GIVEN TO THE MINOR AFTER SHE SIGNS IT. THE ORIGINAL SHOULD IMMEDIATELY BE PLACED IN A SEALED ENVELOPE, WHICH SHOULD BE FILED UNDER SEAL AND KEPT UNDER SEAL AT ALL TIMES PURSUANT TO CODE SECTION 41-44-34(D). 1. My full name is (Please Print) , South Carolina. , and

my address is 2.

I have filed a petition under seal, under the name "Jane Doe."

I declare, under penalty of contempt of court, that the foregoing is true and correct.

Dated: Signature

SCCA/464