Petition For Waiver Of Parental Notice For Abortion Requested By A Minor {NHJB-2383-S}

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: (Mandatory) Case Name: (completed by court staff) Case Number: (completed by court staff) PETITION FOR WAIVER OF PARENTAL NOTICE FOR ABORTION REQUESTED BY A MINOR (RSA132:34) 1. Name of person requesting waiver (You may use your initials, a name other than your own, such as Jane Doe, or your real name.) 2. The following statements are true: I am pregnant. I am less than 18 years old, have never been married and no court has issued an order freeing me from the care, custody and control of my parents. I wish to have an abortion to end my pregnancy. I do not want either one of my parents or legal guardian to be notified that I want an abortion. 3. I understand that the court must hold a hearing and rule on my petition within 2 court business days unless I request an extension of that time period. (Check one of the following boxes.) I request an extension of the 2 court business days time period for ruling. I do not request an extension of the 2 court business days time period for ruling. 4. My legal name is 5. My date of birth is 6. I understand I am entitled to have the court appoint a lawyer to represent me in this matter without cost to me. (Check one of the following boxes.) I want the court to appoint a lawyer for me. I have been working with Attorney represent me and I ask the court to appoint him/her. I do not want a lawyer. 7. I ask the court to allow my doctor to perform an abortion on me without notifying either of my parents or my legal guardian. (Complete Section A or B or both) A. I believe I am mature and capable of giving my informed consent to an abortion because who has agreed to NHJB-2383-S (03/28/2017) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: PETITION FOR WAIVER OF PARENTAL NOTICE FOR ABORTION REQUESTED BY MINOR B. I believe it is in my best interests to have an abortion without notifying either of my parents or a legal guardian because 8. Please provide a confidential phone number to use in reaching you with information about the date and time of the hearing. The court will leave a message if there is no response. If you are unable to provide a confidential phone number for yourself or a phone number for your lawyer, you must file the Petition in person at the courthouse. My CONFIDENTIAL contact phone number is: OR My lawyer's contact phone number is: Date Signature of Plaintiff (Legal name must be used) (If emailing this form, type signature) AFTER YOU HAVE EMAILED THIS PETITION YOU MUST CALL THE COURT'S PARENTAL NOTICE LINE AT (603) 225-4451 HEARING INFORMATION ­ TO BE COMPLETED BY THE COURT A hearing on this matter will be held at the following time and place: Date Time Court name Court address Your court appointed lawyer is: Address Telephone number Guardian Ad Litem (optional) Address Telephone number American LegalNet, Inc. www.FormsWorkFlow.com Telephone number NHJB-2383-S (03/28/2017) Page 2 of 2