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Here is the text we could read:

 

ddress (Optional) 

ity, State, Zip (Optional) 

hone (Optional) 

mail (Optional) 

 
Name 

  A

  C

  P

  E

 

In the Juvenile Court of Utah 

__________ Judicial District ________________ County 
 

State of Utah, in the interest of: 

_____________________________________ 
(Minor’s Name) 

_____________________________________ 
(Minor’s Date of Birth) 

Petition for Waiver of Consent by 
Parent or Legal Guardian to Minor’s 
Abortion 
Utah Code Section 76-7-304.5 

_______________________________ 
Case Number 

_______________________________ 
Judge 

I, the above-named minor, state: 

1. 

2. 

3. 

4. 

I am under the age of 18 years of age and not married or emancipated. My 
birthdate is ______________________. 

I am a resident of __________________________________________________ 

I am approximately ______ weeks pregnant and seek an abortion by a licensed 
physician, without consent from a parent or guardian. 

I understand I have the right to a court-appointment attorney and/or guardian ad 
litem at no cost to me. (Choose one): 

[  ]  a.  Please appoint an attorney and/or guardian ad litem to represent me.   

Reformatted April 5, 2017 / Revised by 
Forms Committee June 30, 2022 
 

Petition for Waiver of Consent by Parent or Legal 
Guardian to Minor’s Abortion 

Page 1 of 3 

[  ]  b.  I have an attorney to represent me. The attorney’s name, address, email 

address, and phone number is 
__________________________________________________________ 

 

 

__________________________________________________________.  

[  ]  c.  I do not want an attorney or guardian ad litem.   

5. 

6. 

I understand that the court will not notify my parents, legal guardians, the father, 
or any member of the public. The only persons who may attend any hearing on 
the petition are court personnel, myself, my attorney, my guardian ad litem and 
those whose presence I specifically request. I request that the following 
person(s) be admitted to all hearings in my case: 

Name(s) and address(es) ___________________________________________ 

________________________________________________________________  

I understand that court personnel will not send any papers to or try to call me at 
my home without my consent. I would like to be informed of the court’s decision 
in the following way (list address, cell phone number, e-mail address, fax 
number, or other): 

________________________________________________________________ 

I request the following person(s), in addition to my attorney and/or guardian ad 
litem, be contacted and given papers in my case: 

Name(s) and address(es) ___________________________________________ 

________________________________________________________________  

7. 

(Check one or both) 

[  ]  a.  I have given my written informed consent to the abortion and I am mature 
and capable of giving informed consent for the performance of an 
abortion. A copy of my written consent is attached.   

[  ]  b.  An abortion is in my best interest for the following reasons.   

________________________________________________________________  

________________________________________________________________  

________________________________________________________________  

Reformatted April 5, 2017 / Revised by 
Forms Committee June 30, 2022 
 

Petition for Waiver of Consent by Parent or Legal 
Guardian to Minor’s Abortion 

Page 2 of 3 

8. 

I state that (check one) 

[  ]  a.  I am presenting this request to a court for the first time.   

[  ]  b.  I have made this request to a court before and was denied. The judge on 

that case was ______________________________________________.   

9. 

The name, business address and business telephone (if these are known) of the 
physician who will perform the abortion is _______________________________ 

________________________________________________________________  

THEREFORE, I request that the court grant my Petition. 

I declare under criminal penalty under the law of Utah that everything stated in this document is true. 

Signed at ______________________________________________________ (city, and state or country). 

Signature ► 

Printed Name 

 

 

 
Date 

       

 

Reformatted April 5, 2017 / Revised by 
Forms Committee June 30, 2022 
 

Petition for Waiver of Consent by Parent or Legal 
Guardian to Minor’s Abortion 

Page 3 of 3

Petition for Waiver of Consent by Parent or Legal Guardian to Minor’s Abortion

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Utah state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from legacy.utcourts.gov (2023-03)
Page(s): 3
Fields(s): 181
Average fields per page: 60
Reading Level: Grade 8
LIST Grouping(s): GO-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

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Suggested Screen 0:

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Petition for Waiver of Consent by Parent or Legal Guardian to Minor’s Abortion

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Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02