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Affidavit Of Clergyperson To Waive Parental Consent For Abortion JC-1621 - Wisconsin
|Affidavit Of Clergyperson To Waive Parental Consent For Abortion Form. This is a Wisconsin form and can be used in Abortion Circuit Court Statewide .||
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FORM SUMMARY Name of Form: Form Number: Statutory Reference: Benchbook Reference: Purpose of Form: Affidavit of Clergyperson to Waive Parental Consent for Abortion JC-1621 §48.375(7)(bm), Wisconsin Statutes JV 15 A member of the clergy may file a "Petition to Waive Parental Consent for an Abortion," (JC-1620), on behalf of a pregnant juvenile. The clergyperson must accompany the petition with an affidavit stating that certain statutory requirements have been complied with. Items 1 through 7 are required by statute. However, since the court may base its ultimate decision solely on the basis of the affidavit, item 8 was added as an optional question to provide additional information to the court. Who Completes it: The clergyperson who files the affidavit must complete it and have it notarized. The original is filed with the Clerk of Circuit Court along with the petition. A copy is provided to the clergyperson and a copy is served on the juvenile. This form must accompany the "Petition to Waive Parental Consent for an Abortion," (JC-1610), when a member of the clergy is filing the petition. It is not required when a pregnant juvenile is filing the petition on her own behalf. A juvenile who wants 24 hours notice of hearings, rather than immediate notice, may also have completed the "Waiver of Immediate Notice (Parental Consent/Abortion Waivers)," (JC-1622). If so, that form may be attached. New Form/Modification: Modifications: Comments: About this form: Modification, last update 7/96. Added a file/date stamp to upper right corner. Added a statement on the bottom indicating that the form shall not be modified. None. This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office and a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. Date: 05/31/00 American LegalNet, Inc. www.FormsWorkflow.com Distribution: Accompanying Forms: For Official Use STATE OF WISCONSIN, CIRCUIT COURT, IN THE INTEREST OF Jane Doe, COUNTY Affidavit of Clergyperson to Waive Parental Consent for Abortion Case No. Date of Birth a person under the age of 18. Under oath I state that: 1. My name is 2. My address is 3. I am an ordained clergyperson for 4. I have personally met with the minor who is the subject of the petition to waive parental consent. 5. I have explored with the minor the alternative choices available to her for managing the pregnancy, including: · carrying the pregnancy to term and keeping the infant; · carrying the pregnancy to term and placing the infant with a relative or with another family for adoption; or · having an abortion. 6. I have discussed with the minor, the possibility of involving one of the following people in her decision-making concerning her pregnancy: · one of her parents; · her guardian or legal custodian, if one has been appointed; · an adult member of her family (grandparent, aunt, uncle, sister, or brother), who is at least 25 years of age, or · one of her fosterparents, if she has been placed in a foster home, and her parent has signed a waiver granting the department, a county department under §§46.215, 46.22, or 46.23, or the foster parent, the authority to consent to medical services or treatment on her behalf. 7. I have discussed with the minor, whether or not involvement of one of the persons named in item 6 above would be in her best interests. It is her opinion such involvement would not be in her best interests. Question 8 is optional: 8. I have the following impressions concerning the minor and this decision: (State any other facts that you believe may be relevant to the court concerning this decision.) . . . Subscribed and sworn to before me on Signature of Clergyperson Notary Public, State of Wisconsin My commission expires: JC-1621, 05/00 Affidavit of Clergyperson to Waive Parental Consent for Abortion Page 1 of 1 §48.375(7)(bm), Wisconsin Statutes. American LegalNet, Inc. www.FormsWorkflow.com This form shall not be modified. It may be supplemented with additional material.