Fla. R. Juv. P. Form 8.988

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.)