© Abortion and Contraception Clinic of Nebraska, January 14, 2010
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Abortion & Contraception Clinic of Nebraska
Caring for women for more than twenty years with
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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-
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.