The following shall be sufficient form of affidavit and application for waiver of parental notice requirement under this subchapter:
IN THE FAMILY COURT OF THE STATE OF DELAWARE
IN AND FOR (NAME OF COUNTY) COUNTY
IN THE MATTER OF: ) AFFIDAVIT AND
) APPLICATION FOR
(NAME OF MINOR APPLICANT), ) WAIVER OF NOTICE
) OF
) ABORTION
STATE OF DELAWARE )
)
________ COUNTY, SS: )
BE IT REMEMBERED that on this __________ day of ____________ , A.D. ________
before me, (name of person authorized to perform notarial acts), personally appeared
(name of minor applicant/affiant) who, being by me duly sworn or affirmed,
depose and say:
applicant minor) and leave telephone messages for the applicant minor at
(phone number designated by applicant minor);
requirement of § 1783 of Title 24;
enough to make the abortion decision on her own and/or it would be in her best
interest that a waiver of notice be granted because (state reasons why mature
and well-informed enough and/or waiver of notice is in best interest based
upon the applicant's age and family circumstances and the long-term and
short-term consequences to the applicant of termination or continuation of the
pregnancy.
WHEREFORE, this minor applicant intends to submit this affidavit and
application for waiver of notice of abortion to the Family Court, and pray
that an order be issued waiving the notification requirement of § 1783 of
Title 24 as to the following persons: (identify each such person).
............................
Minor applicant/affiant
SWORN TO or affirmed and subscribed before me by the minor applicant/affiant
this ________ day of ________ , A.D. ________ .
............................
(Notary)
24 Del. C. § 1785