Vernon's Texas Rules Annotated - VTRA TX R PARENT NOT Form 2A . CONFIDENTIAL APPLICATION FOR WAIVER OF PARENTAL NOTIFICATION AND CONSENT: COVER PAGE

As prescribed by the Clerk of the Supreme Court of Texas pursuant to Tex. Fam. Code § 33.003(m).

(Do not complete this section. Court staff will complete this section.)

CAUSE NO. _______________________________________

IN RE JANE DOE

IN THE __________________________________________

_________________________________________________

________________________

COUNTY, TEXAS

Important: Your Application has two parts: (1) this cover sheet (Form 2A), which asks for basic information about your application; and (2) a separate verification page (Form 2B), which asks for information about you and for you to swear to the truth of everything you say in the cover sheet and verification page. You must complete both of these forms.

1.

I ask the court for an order that allows me to have an abortion without first telling and obtaining the consent of my parent, managing conservator, or guardian. I swear or affirm that (place a check mark in all the blanks for which you answer “yes”):

_______

I am pregnant.

_______

I am unmarried and younger than 18 years of age.

_______

I do not have an order from a Texas court that gives me the same legal rights and responsibilities as an adult.

2.

I request this order for one of the following reasons (place a check mark beside any that apply):

_______

I am mature enough to decide to have an abortion without telling and obtaining the consent of my parent, managing conservator, or guardian. I also know enough about abortion to make this decision.

_______

Telling my parent, managing conservator, or guardian that I want an abortion and attempting to obtain his or her consent is not in my best interest.

_______

Telling my parent, managing conservator, or guardian that I want an abortion may lead to physical or emotional abuse of me.

_______

Telling my parent, managing conservator, or guardian that I want an abortion may lead to sexual abuse of me.

3.

Please check all that apply:

_______

I live in the county where this application is being filed.

_______

My parent, managing conservator, or guardian is a presiding judge of a district court, a county court at law, or a court having probate jurisdiction in the county where I live, and (check any that apply):

_______

The county where I live is contiguous to (shares a border with) this one.

_______

I intend to obtain the abortion in this county.

_______

The population of the county where I live has a population of less than 10,000, and (check any that apply):

_______

The county where I live is contiguous to (shares a border with) this one.

_______

I intend to obtain the abortion in this county.

_______

I am not a Texas resident, but I intend to obtain the abortion in this county.

4.

Please check one of the following statements:

_______

I do not have a lawyer. (The court will appoint one for you).

_______

I have a lawyer, who is:

Lawyer's name: ______________________________________________________________________

Lawyer's email address: _____________________________________________________________

Lawyer's address: ___________________________________________________________________

Lawyer's phone: _____________________________________________________________________

5.

The court must appoint a “guardian ad litem” for you. A guardian ad litem meets with you before the hearing and helps the judge decide your application. Please state whether you want the court to appoint someone you know as your guardian ad litem. This person could be a relative, a member of the clergy, a counselor, a psychiatrist or psychologist, or another adult. You do not have to ask the court to appoint someone you know. Keep in mind that the court may appoint the person you request, but it does not have to.

_______

I am requesting that the court appoint someone I know as my guardian ad litem. (You will identify this person on your verification page.)

_______

I am not requesting the court to appoint someone I know as my guardian ad litem. (The court will appoint someone it chooses.)

6.

Please state whether you have filed a Confidential Application for Waiver of Parental Notification and Consent other than this one with respect to your current pregnancy.

_______

I have filed another Confidential Application for Waiver of Parental Notification and Consent with respect to my current pregnancy.

_______

I have not filed another Confidential Application for Waiver of Parental Notification and Consent with respect to my current pregnancy.

7.

If you have filed another Confidential Application for Waiver of Parental Notification and Consent with respect to your current pregnancy, please answer the following questions. If you have not filed another Application with respect to your current pregnancy, do not answer these questions.

What court ruled on your previous application? _____________________________________________

Has there been a material change in circumstances since the time your previous application was denied? (Write “yes” or “no.”)