Certification Of Emancipated Minor Status printable pdf download

Certification Of Emancipated Minor Status

Falls Church Healthcare Center

900 South Washington Street, Suite 300; Falls Church VA 22046

CERTIFICATION OF EMANCIATED MINOR STATUS:

I __________________________________________________________CERTIFY that I am an

Print full name

EMANCIPATED MINOR as defined by Commonwealth of Virginia Code Article 15 (16.1-331 et seq.)

because I am (initial only those that apply):

_____ entered into a valid marriage, even though the marriage may have been terminated by dissolution

_____ active duty with any of the armed forces of the United States

_____willingly living separate and apart from my parents, guardian, with the consent or acquiescence of

my parents or guardian

_____have an order of emancipation pursuant to Article 15 of the Virginia Code

My birth date:

signed by________________________________________________________

date_______________

staff witness:_____________________________________________

STAFF NOTES:

Certification of Emancipated Minor Status English - Minor-Notary Forms & Brochures – 6-03

Certification Of Emancipated Minor Status