Declaration Form If someone you know has had an abortion, encourage them to complete this form. DECLARATION HOW MY ABORTION HURT ME State of * County of * My name is * Acknowledgement * I am over the age of eighteen years, and I am of sound mind competent to make this declaration. I have personal knowledge of the facts stated in this declaration, and I declare under penalty of perjury the following: 1) When and where did your abortion occur? (Please include city and state.) * 2) How many weeks pregnant were you? * Your estimate Medical Provider Data 3) What type of abortion was performed? * Pill Suction Saline D&C OtherOther If you took the abortion pill, how did you get the pill? In Person Doctor Online Doctor/Telemedicine Online or Mail Friend/Family Pill was forced on me OtherOther 3b) Did you have abortion complications? If so, what happened? * 3c) Did anyone tell you to lie, cover-up, or mislead medical providers or others who treated you after taking the pill? * yes no If so, who? 4) Were you adequately informed of the nature of abortion, what it is, what it does? * yes no If no, explain. 5) Were you adequately informed of the consequences of abortion? * yes no If no, explain. 6) Was your abortion due to rape, incest, fetal anomalies, mother’s health? Explain: 7) Did anyone pressure you into having an abortion? * yes no If yes, what happened? 8) How has abortion affected you? * 9) How has your abortion affected others in your life? * 10) Did you have problems you did not expect after your abortion? * 11) Based upon your experience, what would you tell a woman considering abortion? * 12) Based on your own experience, what would you tell someone that believes abortion should be legal? * Additional information about my testimony “I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct..” Executed this Please use my * Full name First name only Initials only THE FOLLOWING PERSONAL INFORMATION IS KEPT CONFIDENTIAL BY THE JUSTICE FOUNDATION Your Full Name * Phone * E-mail * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Signature signature keyboard Clear I also authorize The Justice Foundation to file Friend of the Court briefs on my behalf to ban or restrict abortion Submit If you are human, leave this field blank. Δ
