Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

CONFIDENTIAL INFORMATION
FOR PROCEEDINGS CONCERNING
WAIVER OF PARENTAL CONSENT

FILE NO.

In the matter of the petition of

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

Initials

Certain information about you is being requested by the court for two reasons:

1. In case the court needs to contact you while this proceeding is pending.

2. To identify who you are in a court order if your petition for waiver of parental consent is granted.

• This information is strictly confidential and will be kept by the court in a sealed envelope marked confidential in a private file.

It is available only to the judge, specifically authorized court personnel, yourself, your attorney, and anyone else you authorize.

•

•

If the court grants your petition, your name and date of birth will be stated in the order.  However, an order granting your petition
will also be kept in the sealed envelope marked confidential.

If the court denies your petition and you appeal the court's order, your entire file (including the sealed envelope containing this
information) will be provided to the Court of Appeals.

Please print in the boxes provided below the following information:

1. Your full name.

2. Your date of birth.

3. Your permanent residence (address, city, zip).

4. The initials you will be using in the title of this proceeding; for example, "In the matter of the petition of

, a minor."

5. How the court or your attorney can get in contact with you; for example, a telephone number.

Minor's full name

Date of birth

Initials used in title

Permanent residence

Means of contact

I declare that this confidential information is true to the best of my information, knowledge, and belief.

Date

Signature of minor

Do not write below this line - For court use only

PC 122  (9/10)   CONFIDENTIAL INFORMATION FOR PROCEEDINGS CONCERNING WAIVER OF PARENTAL CONSENT

MCR  3.615