STATE OF SOUTH CAROLINA	)	IN THE FAMILY COURT
)	JUDICIAL CIRCUIT
COUNTY OF	)
)
)
A JUVENILE	)	DECLARATION OF MINOR
)	UNDER THE AGE OF SEVENTEEN (17)
)	YEARS
)
)
A Child under Seventeen (17) Years of Age	)	Docket No.
NOTICE TO THE CLERK OF COURT: A CERTIFIED COPY OF THIS DECLARATION, WITH THE FILE NUMBER NOTED ON IT, SHOULD BE GIVEN TO THE MINOR AFTER SHE SIGNS IT.

THE ORIGINAL SHOULD IMMEDIATELY BE PLACED IN A SEALED ENVELOPE, WHICH SHOULD BE FILED UNDER SEAL AND KEPT UNDER SEAL AT ALL TIMES PURSUANT TO CODE SECTION 41-44-34(D).

1.	My full name is , and my address is , South Carolina .

2.	I have filed a Petition under seal, under the name “Jane Doe.” I declare, under penalty of contempt of court, that the foregoing is true and correct.

Date: _____________________________	____________________________________

____________________________, S.C.	Signature

SCCA 464 (12/2009)

STATE OF SOUTH CAROLINA

Judy M. Riser

2009-12-14

wclark

Dell Computer Corporation