STATE OF NEBRASKA

  Form No. 14:7 1/98 Rev

  Sec. 71-6903

PETITION FOR WAIVER OF

PARENTAL NOTIFICATION

CASE NUMBER

 

 

 

IN THE ______________ COURT OF _____________________ COUNTY, NEBRASKA

(County, District or Separate Juvenile)  

 

IN THE MATTER OF THE PETITION OF:

        Name:__________________________________________

        Address: ________________________________________

        ________________________________________________

        Date of Birth: ___________________

 

 

PETITION FOR

WAIVER OF

PARENTAL

NOTIFICATION

 

CONFIDENTIAL

 

            THE PETITIONER moves the court for authorization for her physician to perform an abortion without prior notification being required or given to her parent(s) or guardian.

            PETITIONER bases her motion on one of the following alternative grounds:

                  1.                 She is mature and capable of giving informed consent to the proposed abortion.

         2.                 If the court determines that she is not mature or she does not claim to be mature, a waiver of parental notification is in her best interests.

      THEREFORE, the petitioner requests an order authorizing her physician to perform an abortion at her request and without prior notification being required or given to her parent(s) or guardian.

           

      Date: ______________________

                                                        Petitioner’s Signature: _______________________

                                                        Attorney:___________________________________

                                                        ___________________________________________