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1 23456789 10111213141516171819202122232425 262728 Application for Decree of Emancipation 1 IN THE CIRCUIT OF THE STATE OF OREGON FOR THE COUNTY OF ____________ Juvenile DepartmentJuv. No. In the Matter of the Emancipation of ) ) ) APPLICATION FOR DECREEOF EMANCIPATION Applicant ) The Applicant states as follows: I. I was born on the day of , ____ and I am now years of age. II. I currently reside at ________________________________, in the city of _____________, County of ____________, Oregon, and I intend that _____________ County be my place of residence for the indefinite future. III. My custodial parent(s) or guardian(s) do ____ do ____ not consent to my emancipation. 1 23456789 10111213141516171819202122232425 262728 Application for Decree of Emancipation 2 IV. I am substantially able to be self-sufficient and self-supporting without parental guidance and supervision. V. I am sufficiently mature and knowledgeable to manage my own affairs without parental assistance. WHEREFORE, I request that the Court enter a Decree as follows: A. Declaring me to be an emancipated minor; B. Advising me of my civil and criminal rights and liabilities; and C. Instructing me to obtain from the Oregon Motor Division an Oregondriver’s license or identification card with a notation thereon of my emancipated status. _______________________________ ___________________________ Parent’s Name Applicant _________________________________ ______________________________ Street Address Street Address _______________________________ ____________________________ City, State, Zip Code City, State, Zip Code _______________________________ ____________________________ Phone Phone ____________________________ Applicant Signature 1 23456789 10111213141516171819202122232425 262728 Application for Decree of Emancipation 3 SUBSCRIBED AND SWORN to me before this _______day of _____________________, _______. Notary Public for Oregon My Commission expires__________________ _____________________________________