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TY AND ZIP CITY: BRANCH NAME: IN THE MATTER OF (NAME): Petitioner, a minor PETITION FOR DECLARATION OF EMANCIPATION OF MINOR CASE NUMBER: ORDER PRESCRIBING NOTICE DECLARATION OF EMANCIPATION ORDER DENYING PETITION 1. My name: My address: I am a resident of or temporarily domiciled in this county. 2. I request that the court declare me to be emancipated. 3. a. I am at least 14 years of age and my date of birth is: b. I am willingly living separate and apart from my parents or legal guardian.

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