IMPOUNDED
PETITION
(Pursuant to G.L. c. 112, § 12S)
DOCKET NUMBER
CASE NAME:
Trial Court of Massachusetts
The Superior Court
COURT NAME & ADDRESS
IN THE MATTER OF MARY MOE
AOSC 6/2019
County
Clerk of Courts
MARY MOE
Dated
1. This action is brought pursuant to G.L. c. 112, § 12S. By this action, the plaintiff, a woman under the age of
eighteen (18) years, seeks an order of the Court permitting her to obtain an abortion without parental consent.
The plaintiff has decided not to seek the consent of a parent or guardian.
2. The plaintiff is
4.
years of age and is not married.
The plaintiff's parent or guardian has refused to consent to the performance of an abortion.
WHEREFORE, the plaintiff requests: [cross out any that do not apply]
1. That this Court enter an Order authorizing a physician to perform an abortion on plaintiff without parental
consent.
2. That these papers be IMPOUNDED, to protect the privacy of the plaintiff.
3. That this Court waive payment of all fees and costs by plaintiff.
4. That this Court appoint an attorney to represent the plaintiff at the expense of the Commonwealth.
PLEASE SIGN "MARY MOE" AND SIGN THE CONFIDENTIAL AFFIDAVIT PROVIDED BY THE CLERK
USING YOUR OWN NAME.
3. The plaintiff believes that she is approximately weeks pregnant.
The plaintiff is unable to pay the fees and costs of this proceeding.
5.
