The following shall be sufficient form of affidavit and application for waiver of parental notice requirement under this subchapter:

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:

(1) That the minor applicant resides at (minor’s address);

(2) That the Court may send its order to (mailing address designated by applicant minor) and leave telephone messages for the applicant minor at (phone number designated by applicant minor);

(3) That the minor applicant is pregnant;

(4) That the minor applicant desires to obtain an abortion;

(5) That the minor applicant desires that the Court waive the notice requirement of § 1783 of Title 24;

(6) That the minor applicant believes that she is mature and well-informed 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:

Minor applicant/affiant

SWORN TO or affirmed and subscribed before me by the minor applicant/affiant this ____ day of ________ , A.D. ____ .

(Notary)

70 Del. Laws, c. 238, § 1; 70 Del. Laws, c. 186, § 1.