Confidential Verification {ACA-02}

CONFIDENTIAL VERIFICATION COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA (JUVENILE COURT SECTION OF THE FAMILY DIVISION) " ORPHANS' OR " FAMILY COURT DIVISION IN RE: Matter of (Initials) , A Minor : : Application No. of 2 1. I, (initials only), am the applicant in a separate application for an abortion under Section 3206 of the Abortion Control Act, 18 Pa.C.S. § 3206. The name and address of each of my parents, guardian or person standing in loco parentis is as follows (please print): Father: Name Street City, State, Zip Mother: Name Street City, State, Zip Guardian: Name Street City, State, Zip 2. Form ACA-02 rev. 10.13.06 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com IN RE: Matter of (Initials) , A Minor 3. I verify that the statements made in the separate application and in this unsworn verification are true and correct to the best of my personal knowledge or information and belief. I understand that false statements herein are made subject to penalties of Section 4904 of the Crimes Code, 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities. Applicant's Signature (Initials may be used as signature) Applicant's Date of Birth Date Form ACA-02 rev. 10.13.06 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com