Petition For Declaration Of Emancipation Of A Minor (Page 3 of 3) in pdf

Petition For Declaration Of Emancipation Of A Minor Page 3

This person’s relationship to me is:________________________

I am a [ ] dependent child [ ] probation ward of the juvenile court of

Case number (if known)

My probationer officer is (name):_________________________________

I am in state custody. yes/no. (circle one)

The state agency with custody is: ___________________________

I declare under penalty of perjury that the foregoing is true and correct and that this

declaration is executed at (place):_______________________, Utah.

on (date):__________________.

_____________________________

Petitioner

Notary Clause

_______________________________, Petitioner, is personally known to me or presented satisfactory

proof of identity to me. After being sworn and while under oath, Petitioner stated that he or she was

acting voluntarily, had read and understood the preceding document, and that the contents were true.

Petitioner then signed the document in my presence.

Signed on__________________________, 20_____.

X____________________________________

Notary Public/ Court Clerk

(Notary Seal)

May 6, 2006

Petition For Declaration Of Emancipation Of A Minor Page 3