[29 Pa.B. 4544]

[Continued from previous Web Page]

COMMONWEALTH OF PENNSYLVANIA	:
	:	ss.
COUNTY OF BERKS	:

   The above-named petitioner __ , _________________ , being duly ______ , do _____ depose and say that the facts set forth in the foregoing petition are true to the best of ______ knowledge and belief.

__________

         Signature of Petitioner

______ to and subscribed before me this _________________ , 19 ______ .  
__________

[ALTERNATIVE]

   I, ______ , verify that I am [a/the] Petitioner in the within Petition, and that the facts contained in the foregoing Petition are true and correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa.C.S.A. § 4904 relative to unsworn falsification to authorities.

Dated: _________________         __________

Petitioner

PETITION FOR ADJUDICATION
TESTAMENTARY TRUSTEES/GUARDIANS

COURT OF COMMON PLEAS, BERKS COUNTY
ORPHANS' COURT DIVISION

Estate of __________

Late of _________________

Account of ___________________________

FILE NO. ______

TO THE HONORABLE, JUDGE OF SAID COURT:

The Petition of _________________ represents that:

   (1)  The decedent died on ______ , 19 __ ;

   (2)   _________________ was appointed trustee in the last will of ______ , dated ______ duly probated in the office of the Register of Wills, on the ______ day of ______ , 19 __ , a copy of which will is hereunto attached and marked ''Exhibit A,'' or by other proceeding.⁹

   (3)  The trust arises as follows:¹⁰

   (4)  Accounts of the fund have heretofore been filed on the following dates: _________________ ;

   (5)  The occasion of the present account is: ___________________________  
__________
_______________________________________________ ;

   (6)  The names of the parties in interest given notice of the audit, the amount and nature of their interests are as follows:¹¹

   

Name and Residence	Relationship	Interest	Of Age	Name of Guardian or
			(Yes	Committee, if any,
			or No)	and how appointed

   (7)  The questions for adjudication are as follows:¹²

   (8)  The distributive shares of principal and income should be in conformity with the distributive shares set forth in a Schedule of Proposed Distribution to be filed at or before the date fixed for audit.

   Your petitioner, therefore, asks that distribution be awarded to the persons thereunto entitled, as their respective interests may appear.

__________

               Signature of Petitioner

__________

                     Address

__________

   There shall be submitted herewith the following:

   (   )   Attorney's Certificate of Notice

   (   )   Proposed Decree Nisi

   Any item checked not attached hereto shall be submitted at or before audit.

COMMONWEALTH OF PENNSYLVANIA	:
	:	ss
COUNTY OF BERKS	:

   The above-named petitioner __ , _________________ , being duly ______ , do _____ depose and say that the facts set forth in the foregoing petition are true to the best of ______ knowledge and belief.

__________

         Signature of Petitioner

______ to and subscribed before me this _________________ , 19 ______ .  
__________

[ALTERNATIVE]

   I, ______ , verify that I am [a/the] Petitioner in the within Petition, and that the facts contained in the foregoing Petition are true and correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa.C.S.A. § 4904 relative to unsworn falsification to authorities.

Dated: _________________         __________

Petitioner

IN RE: APPLICATION OF	:	IN THE COURT OF COMMON PLEAS
_____  _____  _____ ,	:	OF BERKS COUNTY, PENNSYLVANIA
[initials only]	:	ORPHANS' COURT DIVISION
	:
A Minor	:	File No.

APPLICATION OF A MINOR PURSUANT TO 18 Pa.C.S.A. Section 3206 FOR DECLARATION OF MATURITY TO CONSENT TO AN ABORTION OR IN THE ALTERNATIVE FOR DECLARATION OF AUTHORIZATION OF ABORTION AS BEING IN THE MINOR'S BEST INTERESTS.

TO THE HONORABLE, THE JUDGES OF SAID COURT:

   The Petition, of  ______ respectfully represents:
[initials]

   1.  Applicant is a ______ year old female, having been born on ______ .
[age][month/day/year]

   2.  The names and addresses of applicant's parents are:
 
__________
 
__________
 
__________
 

   3.  Applicant is currently with _________________ at _________________ . (If other than parent(s) indicate relationship of party residing with. If guardian, provide term and number of court order of appointment. __________

   4.  Check one:

   (   )   I have discussed my decision to have an abortion with my parent(s)/guardian(s) and she/he/they have refused to consent to such procedure.

   (   )   I have not discussed my decision to have an abortion with my parent(s)/guardian(s) and I do not wish to seek his/her/their consent.

   5.  A medical determination of pregnancy was made on ______ by ______ which revealed [date][physician]
that I am approximately ______ weeks pregnant, and that there are no apparent medical contraindications to the performance of an abortion. A verification of medical provider is attached hereto as Exhibit A.

   6.  The name of the physician who will perform the abortion if authorized by this Court is ______ .

   7.  The abortion will be performed at ______ , Berks County, Pennsylvania, on or about ______ , but no later than ______ .

   8.  The requirements of the Abortion Control Act regarding informed consent have been satisifed. As proof there- of attached hereto as Exhibit B is an Informed Consent Verification certifying that on ______ , [date]      
 _________________ orally informed me of the nature, alternatives and risks of the proposed abortion   [name of informant & position/title]
procedure. Attached hereto as Exhibit C is a Certification of Receipt of Section 3205(A) Information.

   9.  I understand that I have the right: to be represented by counsel appointed by the Court at no cost to me; or to retain the lawyer of my choice at my expense; or to waive my right to representation by legal counsel.

   10.  Check one:

   (   )   I want the Court to appoint a lawyer to represent me in this proceeding at no cost to me.

   (   )   I have retained a lawyer to represent me at my own expense. My lawyer is _________________  [name]                     
__________
[address]

   (   )   I do not choose to be represented by a lawyer at the hearing on this application. I wish to participate in the hearing on my own behalf but want the Court to appoint a guardian ad litem to assist me.

   (   )   I do not choose to be represented by a lawyer at the hearing. I wish to participate on my own behalf at the hearing on this application and do not want the Court to appoint a guardian ad litem to assist me.

   11.  I am of sound mind and believe that I possess sufficient maturity, information and intelletual capability to consent to the proposed abortion procedure. In support hereof attached hereto as Exhibit D is a completed Questionnaire of General Information. (Completion of Exhibit D is voluntary. You do not have to fill it out at all. However, at the hearing similar questions will be posed to you).

   12.  I have given my written consent to the performance of an abortion on me, which is attached hereto as part of Exhibit C.

   13.  I request that the Court grant me full capacity for the purpose of consenting to an abortion.

   14.  In the alternative, should this Court determine that I am not mature and capable of giving informed consent, I request the Court to find that an abortion is in my best interests for the following reasons:
 
__________ 
__________ 
__________ 
__________ 
__________ 

   15.  I am aware that any false statements made in this petition are punishable by law.

   WHEREFORE, your petitioner prays this Honorable Court to schedule this matter for hearing within such time as shall permit a decree of this Court to be entered within three business days of the filing of this application, and that a decree be entered declaring that I am mature and capable of giving informed consent to the abortion sought, and have given such consent, or, in the alternative, that the abortion is in my best interests, and authorizes the medical provider to perform the abortion procedure.

Respectfully submitted,
 
_________________
            Signature

EXHIBIT A

IN THE COURT OF COMMON PLEAS OF
BERKS COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION

IN RE:  MATTER OF ______ ,
A MINOR      [INITIALS]

VERIFICATION OF MEDICAL PROVIDER

   I, _________________ , under penalty of perjury do hereby affirm and depose that the following facts are          [name of medical provider]
true and correct to the best of my knowledge, information, and belief.

   1.  I am currently employed at ______ as a ______ in ______ , PA.
[medical facility]                  [occupation]

   2.  I have examined ______ , a minor, the petitioner in the above-captioned case.
[initials]

   3.  Petitioner desires to terminate her pregnancy and has consulted me for this purpose.

   4.  Based on our discussion and my examination I have concluded the following:

   a.  Petitioner's last menstrual period was on ______ ; she is therefore ______ weeks pregnant.

   b.  In my best judgment the abortion is necessary in light of the physical, emotional, psychological, familial factors and the minor's age.

   c.  There are no apparent medical contraindications to the performance of the abortion.

   d.  Further comments of the medical provider if you so desire: __________
 
__________
 
__________
 
__________
 
_________________
[Signature of Medical Provider]

EXHIBIT B

INFORMED CONSENT VERIFICATION

   A.  I, _________________ , am the referring physician/physician performing the abortion (indicate which) on [name of physician]
______ which abortion will be performed at _________________ . I have orally [initials of minor][name of facility where procedure will be performed]
informed _________________ , a ____ -year-old who is approximately ______ weeks pregnant, of                      [initials of minor]
the following:

   1.  The nature of the proposed abortion procedure, known as ______ , as follows:
 
__________
 
__________ 

   2.  The risk(s) of the proposed abortion procedure is (are) as follows:
 
__________
 
__________
 

   3.  The alternatives to the present abortion procedure are as follows:
 
__________
 
__________
 

   4.  The probable gestational age of the unborn child, at the time the proposed abortion is to be performed is ____ weeks.

   5.  The medical risks associated with carrying the child to full term are the following:
 
__________
 
__________
 

   I verify that the above statements are true and correct according to the best of my knowledge, information and belief and understand that false statements herein are subject to the penalties of 18 Pa.C.S.A. § 4904 relating to unsworn falsification to authorities.

 ______  ______  _________________ 
Date
Time
[signature of physician]               

   B.  I, the above-named physician or a qualified physician assistant, technician, or social worker to whom the above-named physician has assigned responsibility, have informed ______ of the following:
[initials of minor]

   1.  The Department of Health of the Commonwealth of Pennsylvania publishes printed materials which describe the unborn child and lists agencies which offer alternatives to abortion and that she has a right to review such printed materials and that a copy will be provided to her free of charge if she chooses to review it.

   2.  Medical assistance benefits may be available for prenatal health care, childbirth and neonatal care and that more detailed information on the availability of such assistance is contained in the printed materials published by the Pennsylvania Department of Health.

   3.  The father of the unborn child is responsible to assist in the support of the unborn child if carried to full term and delivered even where he has offered to pay for an abortion. (This information may be omitted in rape cases.)

   C.  The above-mentioned printed materials [were/were not] requested and [were/were not] provided.

   I verify that the statements under B. & C. above are true and correct according to the best of my knowledge, information and belief and understand that false statements herein are subject to the penalties of 18 Pa.C.S.A. § 4904 relating to unsworn falsification to authorities.

 ______      ______      ___________________________
Date                                 Time                                    [signature of physician or physician's designee]

EXHIBIT C

CERTIFICATION OF RECEIPT OF INFORMATION REQUIRED BY SECTION 3205(A) OF THE ABORTION CONTROL ACT (18 Pa.C.S.A. SECTION 3205(A)

   I, ______ , am ____ years old and am approximately ____ weeks pregnant. I certify that on ______ , [initials of minor]
[date]      
_________________ of _________________ orally informed me of the proposed [name of informant and position]                     [name of facility/clinic]
abortion procedure, known as _________________ .

   I further certify that ______ also informed me of the nature, risks, consequences, and possible [informant]
alternatives to the proposed abortion procedure and, additionally, the other required information under Section 3205(a), and I am satisfied that I have been provided enough information to enable me to decide whether or not to undergo the proposed abortion procedure.

   I consent to the performance of an abortion upon me by _________________ . This consent is knowing and voluntary.

Date: ______	___________________________
	[initials of minor]

EXHIBIT D

GENERAL INFORMATION QUESTIONNAIRE

   I, ______ , certify that the information provided below is true and correct to the best of my knowledge, initials
information and belief.

A.  EDUCATION

     1.  Are you currently in school?      YES ______      NO ______

      (a)  If not, what was the last grade you completed? __________

      (b)  Why did you leave school? __________
 
__________
 
__________

      (c)  Do you plan to return to school and, if so, when? __________
 
__________

     2.  What grade are you in? __________

     3.  Do you plan to finish high school?      YES ______      NO ______

     4.  Do you plan to go on to further school after graduation from high school?      YES ______      NO ______

     5.  What profession or occupation do you plan to pursue after completing your education? __________
 
__________

B.  INTERESTS

     6.  Are you involved in extra-curricular activities at school?      YES ______      NO ______
If yes, what are they? __________
 
__________
 
__________

     7.  Are you involved in community activities/civic groups (e.g. scouting, volunteer work, church groups)? YES ______      NO ______
If yes, what are they? __________
 
__________
 
__________
 
__________

     8.  What are your hobbies, interests or forms of recreation? __________
 
__________
 
__________
 
__________

C.  EMPLOYMENT

     9.  Are you currently employed?            YES ______      NO ______
(a)  Full-time                                 YES ______      NO ______
(b)  Part-time                                 YES ______      NO ______
     How many and what hours do you work? __________
(c)  Are you paid at least minimum wage?      YES ______      NO ______

   10.  How long have you held this job? __________

   11.  What kind of work do you do? __________
 
__________
 
__________
 
__________

   12.  List and briefly describe other jobs you have held in the past 3 years? __________
 
__________
 
__________
 
__________ 
__________
 
__________
 
__________

D.  FAMILY

   13.  With whom do you live, and what is their relationship to you? __________
 
__________
 
__________

   14.  How many other people over 18 live in your home, and what is their relationship to you? __________
 
__________
 
__________
 
__________

   15.  Do you have any responsibilities at home? (e.g. household chores; care of younger children or disabled relatives) YES ______      NO ______
If yes, list them. __________
 
__________
 
__________
 
__________
 
__________

E.  HEALTH

   16.  What is the general state of your health? __________
 
__________
 
__________

   17.  Do you have any chronic or recurrent health problems which might influence your decision to end your pregnancy? YES ______      NO ______
If YES, please describe. __________
 
__________ 
__________
 
__________
 
__________

F.  DECISION TO SEEK ABORTION

   18.  Have you discussed your decision to abort your pregnancy with the biological father of the fetus?      YES ______      NO ______
(a)  If YES, what was his reaction to your decision? __________
 
__________
 
__________
(b)  If NO, why have you not informed him of your choice? __________
 
__________
 
__________

   19.  If you have chosen not to seek your parent(s) consent to the proposed abortion, why have you so elected? __________
 
__________
 
__________
 
__________

   20.  Have you discussed your decision to abort your pregnancy with anyone else?      YES ______      NO ______
(a)  If YES, with whom? (Provide age of person(s) and their relationship to you). __________
 
__________
 
__________
 
__________(b)  What advice/reaction did you receive from those persons? __________
 
__________
 
__________
 
__________

   21.  Have you felt that anyone pressured you or forced you to choose abortion?      YES ______      NO ______
If YES, describe who you felt did so and the form of the pressure or force. __________
 
__________
 
__________
 
__________
 
__________

   22.  Have you felt that anyone has pressured you or forced you to continue your pregnancy?      YES ______      NO ______
If YES, describe who you felt did so and the form of the pressure or force. __________
 
__________
 
__________
 
__________
 
__________

   23.  In your own words, please describe why you have decided to seek an abortion? __________
 
__________
 
__________
 
__________ 
__________
 
__________
 
__________ 
__________
 
__________
 
__________
 
__________

   24.  Please provide any information that you feel demonstrates your maturity and ability to give informed consent to an abortion. (You may attach written statements from other persons who feel that you are mature and able to give informed consent. Such attachments must indicate the writer's age, occupation, relationship to you, and the length of time she/he has known you). __________
 
__________
 
__________
 
__________ 
__________
 
__________
 
__________ 
__________
 
__________

   25.  Please indicate whether anyone has assisted you in completing this questionnaire and that person's relationship to you (e.g. friend, sibling, counselor, teacher, etc.) and how long you have known them. __________
 
__________
 
__________
 

[Pa.B. Doc. No. 99-1431. Filed for public inspection August 27, 1999, 9:00 a.m.]

_______

⁹ State any other circumstances of appointment.

¹⁰ State concisely the purpose and terms of trust, how and when established, whether terminated in whole or in part and date and reason therefor, name of any predecessor trustee and accountant's date of appointment. Identify any prior adjudications in which fund was awarded to succeeding or present fiduciary.

¹¹ When required, give notice to Commonwealth, Veterans' Administration or Pa. Department of Revenue. See Rules 5.5, 6.7 and 6.8.

¹² If none, state ''none.'' If any, state questions which are to be adjudicated, presenting all material facts not already given.

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