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and coming soon to South-West Iowa

AbortionClinics.Org

Caring for women for more than twenty years with

KINDNESS, COURTESY, JUSTICE, LOVE and RESPECT

 © AbortionClinics.Org, January 30, 2012

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  1002 W Mission Ave., Bellevue, NE  68005

Nebraska Parental Notification Affidavit

LeROY H. CARHART, M.D.

AND THE

ABORTION & CONTRACEPTION CLINIC OF NEBRASKA

1002 West Mission Avenue, Bellevue, Nebraska  68005 (402) 291-4797

STATE OF  ______________________)          PARENTAL NOTIFICATION AFFIDAVIT                                                      

COUNTY OF _____________________)

1. Comes now______________________________________________, who states, under oath, that she/he is the natural parent or court appointed legal guardian of

____________________________________________.

2.____________________________________ further states, under oath, that she/he has been informed that LeRoy H. Carhart, M.D. will perform an abortion upon her/his daughter and she/he is aware that this abortion will terminate their daughter's pregnancy and that the abortion process is not able to be stopped or reversed once the abortion has been started.

       Signed: _____________________________________

       Social Security Number: ______________________

       Relationship: ________________________________

       Date: _______________________________________

 NOTARY:     I certify that on the ___________ day of _______________ 200___,

 ________________________________________ appeared before me and completed the above affidavit.