Free STATE OF SOUTH CAROLINA - South Carolina

STATE OF SOUTH CAROLINA COUNTY OF

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

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IN THE FAMILY COURT JUDICIAL CIRCUIT FILE NO: PETITION FOR ORDER CONCERNING ABORTION FOR MINOR UNDER THE AGE OF SEVENTEEN (17) YEARS

NOTICE TO THE CLERK OF COURT: THIS PETITION, AS WELL AS ALL PAPERS RELATED TO THIS PETITION, MUST BE FILED UNDER SEAL IMMEDIATELY AND KEPT UNDER SEAL AT ALL TIMES PURSUANT TO CODE SECTION 44-41-34 (D). 1. I am under seventeen (17) years of age and unemancipated (I have never been married and I do not have a court order of emancipation). 2. I am pregnant and I wish to have an abortion. 3. I do not have the consent for an abortion from one of my parents, my legal guardian, one of my grandparents, or another person who is at least 18 years of age who has been acting as my parent for more than 60 days. 4. I request a hearing within 72 hours of filing this petition. 5. I am unable to pay filing fees or any other cost associated with this action, and I request that I not be required to pay such costs. 6. I understand that the court will appoint a guardian ad litem for me; and, (check one) a. I would like the following person, who is at least 18 years of age be my guardian ad litem: , whose address is , South Carolina, telephone number (803) . b. I do not have a preference as to who should be my guardian ad litem. 7. I understand that I have a right to have a court-appointed lawyer assist me free of charge as I am not able to pay an attorney, and (check one): a. I request that the court assign a lawyer to represent me. b. I do not want the court to assign a lawyer to me. 8. I would like any court papers to be sent to my guardian ad litem, to any attorney who may represent me, and [check any that apply]: a. to me, personally, at this address: b. to at this address: c. to no one other than my guardian ad litem, and any attorney who may represent me. 9. I understand that my name and identity will be kept secret and that all my records will be sealed. 10. I am filing a sealed declaration with this Petition, which contains information which identifies me. 11. I ask that the court grant me the right to consent to an abortion because I am mature and well- informed enough to make the abortion decision on my own or to grant consent for the abortion if the court finds that performance of the abortion would be in my best interest. Date: Signature (Note: You may use the name "Jane Doe")

SCCA/461(Rev. 6-1992)