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?

If you took the abortion pill, how did you get the pill?

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 testamony

“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

I also authorize The Justice Foundation to file Friend of the Court briefs on my behalf to ban or restrict abortion