Fill and Sign the Final Order Dismissing Judicial Waiver E Seventh Judicial Form

IN THE CIRCUIT COURT OF THE _____________ JUDICIAL CIRCUIT, IN AND FOR __________________ COUNTY, FLORIDA In the interest of __________________________ Case No.: ___________ (pseudonym or initials of mi nor) Division: ___________ PETITION FOR JUDICIAL WAIVER OF PARENTAL NOTICE OF TERMINATION OF PREGNANCY I certify that the following information is true and correct: (1) The pseudonym or initials of the minor (is/are) _____________________, and the minor has filed a Sworn Statement of True Name and Pseudonym with the clerk. (2) The minor is _____ years old. (3) The minor is pregnant and notice has not been waived. (4) The minor desires to terminate her pregnancy without notice to a parent or legal guardian for one or more of the following reasons: [check all that apply] ___ a. The minor is sufficiently mature to decide whether to terminate her pregnancy, for the following reason(s): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ___ b. The minor is a victim of child abuse or sexual abuse by one or both of her parents or a guardian. ___ c. Notification of a parent or guardian is not in the best interest of the minor, for the following reason(s): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (5) The minor requests that the court enter an orde r authorizing her to consent to the performance or inducement of a termination of pregnancy w ithout notification of a parent or guardian. (6) The minor requests the appointment of an attorney to represent her in this matter: [check one] _____ yes _____ no (7) The minor elects the following method or methods for receiving notices of hearings or other court actions in this case: ___ Through a third party whose name is ___________________________and whose address and phone number for purposes of noti ce is __________________________________________ ______________________________________________,_______________________________. ___ The minor will contact the office of the clerk of court at the following phone number _______________________. I understand that by signing this form I am swearing to or affirming the truthfulness of the claims made in this petition and that the punishment for knowingly making a false statement includes fines, imprisonment, or both. Signature: ____________________________________ Date: ______________ (You may sign a name other than your true name, such as Jane Doe or other pseudonym under which your petition is being filed.)