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 by LeRoy H. Carhart, M.D. that he 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.