FORM 8.988. SWORN STATEMENT OF TRUE NAME AND
PSEUDONYM

SWORN STATEMENT OF TRUE NAME AND PSEUDONYM
NOTICE TO THE CLERK OF COURT: A CERTIFIED COPY OF THIS
DECLARATION WITH THE CASE NUMBER NOTED ON IT SHALL
BE GIVEN TO THE MINOR AFTER SHE SIGNS IT.

THE ORIGINAL SHALL IMMEDIATELY BE PLACED IN A SEALED
ENVELOPE WHICH SHALL BE FILED UNDER SEAL AND KEPT
UNDER SEAL AT ALL TIMES.

(1) My true name is , and my address is
.

(print your name) (print your
address)

(2) My date of birth is .

(3) I have filed a Petition for Judicial Waiver of Parental Notice
and Consent or Consent Only to Termination of Pregnancy under
the name or initials on .
(date)

I understand that by signing this form I am swearing to or affirming
the truthfulness of the information herein and that the punishment
for knowingly making a false statement includes fines,
imprisonment or both.

Dated: Signature:

(You must sign your true name.)