MINOR’S APPLICATION FOR
JUDICIAL AUTHORIZATION OF AN ABORTION

COURT OF COMMON PLEAS OF
                                             COUNTY, PENNSYLVANIA
(JUVENILE COURT SECTION OF THE FAMILY DIVISION),
“ ORPHANS’ OR “ FAMILY COURT DIVISION

IN RE: Matter of                              , A Minor     : Application No.                                              
                                                        (Initials)

      :

of 2                                                                

TO THE HONORABLE, THE JUDGES OF THE SAID COURT:

Applicant, a minor, whose initials are                              , respectfully states:

1. Applicant is a pregnant woman, who (choose one):

“ is a resident of this county; or

“ seeks an abortion within this county.

2. Applicant’s date of birth is                                                       ,                    .

3. Applicant is approximately                 weeks pregnant.

4. The name and address of each parent or guardian or person standing in

loco parentis are contained in Applicant’s separate unsworn verification.

“ Yes     “ No

5. Applicant desires to terminate her pregnancy and has consulted with the

physician who is to perform the abortion, or with a referring physician, for
that purpose on (date)                                              at               o’clock a.m. /
p.m.  Applicant has been fully informed of the risks and consequences of
the abortion.

“ Yes     “ No

6. Applicant consents to the abortion procedure.

“ Yes     “ No

7. Applicant is of sound mind and has sufficient intellectual capacity to

consent to an abortion.

Form ACA-01   rev. 10.13.06

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IN RE: Matter of                              , A Minor
                                                        (Initials)

“ Yes     “ No

8. Applicant is mature and capable of giving informed consent to the

proposed abortion.

OR

“ Yes     “ No

The performance of an abortion upon the applicant would be in the
applicant’s best interests.

9. Applicant is executing an unsworn verification with respect to statements
of fact in this application.  The unsworn verification is set forth in a
document separate from this application but incorporated herein by
reference.  Applicant is aware that any false statements made in this
application are punishable by law.

Wherefore, Applicant prays this Honorable Court to enter an Order authorizing a

physician to perform an abortion upon Applicant.

Respectfully submitted,

                                                                        
Applicant’s Signature
(Initials may be used as signature)

Form ACA-01   rev. 10.13.06

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