Fill and Sign the Code of Virginia Jurisdiction Consent for Abortion Va Code Form

PETITION FOR JUDICIAL AUTHORIZATION OF ABORTION VA. CODE § 16.1-241 (V) Court Case No. Commonwealth of Virginia Hearing Date and Time PLEASE NOTE: All papers and hearings in this matter are confidential Juvenile and Domestic Relations District CourtIn re a petitioner under eighteen years of age: PETITIONER'S NAME DATE OF BIRTH AGE CONTACT TELEPHONE NUMBER (OPTIONAL) I, the undersigned, request this court to authorize a physician to perfo\ rm an abortion pursuant to Virginia Code § 16.1- 241(V). I verify that the information given above is correct, and that\ I have elected not to allow notice to an authorized person as defined in Virginia Code § 16.1-241(V). DATE PETITIONER'S SIGNATURE Sworn/affirmed and signed before me on INTAKE OFFICER DATE CLERK DEPUTY CLERK NOTARY PUBLIC My commission expires: Petitioner with Intake Officer Filed by: Counsel for Petitioner SIGNATURE OF COUNSEL Date and Time Petition Filed: CLERK DEPUTY CLERK INTAKE OFFICER HEARING DATE A hearing on this petition has been set for m., at the , at DATE TIME Juvenile and Domestic Relations District Court ADDRESS AND COURTROOM COURT TELEPHONE NUMBER I DATE CLERK DEPUTY CLERK INTAKE OFFICER ACKNOWLEDGMENT OF HEARING DATE AND TIME 1. I understand that a hearing on this petition has been scheduled as noted\ above. 2. I acknowledge that I have received a copy of this petition and notice of\ hearing in person on this date. I waive all other forms of notice for hearing on this date. PETITIONER'S SIGNATURE DATE SIGNATURE OF COUNSEL FOR THE PETITIONER FORM DC-502 (A) (PAGE ONE OF ONE) 7/03 PDF