Fill and Sign the Florida Supreme Court Approved Family Law Form 12981a2

In the matter of the petition of , a minor, for waiver of parental consent for an abortion Do not write below this line - For court use only Approved, SCAOFILE NO. PC 119 (9/10) PETITION FOR WAIVER OF PARENTAL CONSENT FOR AN ABORTION PETITION FOR WAIVER OF PARENTAL CONSENT FOR AN ABORTION Initials STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY MCL 722.904, MCR 3.615 Date Name of next friend (type or print) Address of next friendCity, state, zip Initials of minor/Signature of next friendTelephone no. Name (type or print) Address City, state, zip Attorney signature Bar no. Telephone no. 1. I am the minor. next friend of the minor. 2. The minor resides or is found in this county. 3. The minor is pregnant, wants an abortion, and desires to give her own consent to the abortion. 4. The minor requests an order waiving parental consent for the abortion because the minor's parent or legal guardian is not available or refuses to give his or her consent, or the minor has elected not to seek consent of her parent or legal guardian. 5. As next friend, I certify that I am an adult and none of the following: a. a physician who performs abortions. b. a person who is employed by, or receives financial consideration from, a physician who performs abortions or an organization that provides abortions or abortion counseling and referral services. c. a person who serves as a board member or volunteer to an organization that provides abortions or abortion counseling and referral services. I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, a nd belief.