Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

PETITION FOR WAIVER OF
PARENTAL CONSENT FOR AN ABORTION

FILE NO.

In the matter of the petition of

, a minor, for waiver of parental consent for an abortion

Initials

1. I am the

 minor.

next friend of the minor.

2. The minor resides or is found in this county.

3. The minor is pregnant, wants an abortion, and desires to give her own consent to the abortion.

4. The minor requests an order waiving parental consent for the abortion because the minor's parent or legal guardian is not

available or refuses to give his or her consent, or the minor has elected not to seek consent of her parent or legal guardian.

5. As next friend, I certify that I am an adult and none of the following:

a. a physician who performs abortions.

b. a person who is employed by, or receives financial consideration from, a physician who performs abortions or an

organization that provides abortions or abortion counseling and referral services.

c. a person who serves as a board member or volunteer to an organization that provides abortions or abortion counseling

and referral services.

I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and
belief.

Attorney signature

Name (type or print)

Address

City, state, zip

Date

Initials of minor/Signature of next friend

Bar no.

Name of next friend (type or print)

Address of next friend

Telephone no.

City, state, zip

Telephone no.

Do not write below this line - For court use only

PC 119  (9/10)   PETITION FOR WAIVER OF PARENTAL CONSENT FOR AN ABORTION

MCL 722.904, MCR 3.615