Rule 16.5 - Application; Contents; Form of Verification; Assistance in Preparation(a) The application shall set forth the following:(1) the initials of the applicant;(2) the age of the applicant;(3) the names and addresses of each parent, guardian or, if the petitioner is a minor whose parents are deceased and no guardian has been appointed, any other person standing in loco parentis to the applicant;(4) a statement that the applicant has been fully informed of the risks and consequences of the abortion;(5) a statement whether the applicant is of sound mind and has sufficient intellectual capacity to consent to the abortion;(6) a prayer for relief asking the court to enter an order authorizing a physician to perform an abortion upon applicant;(7) an unsworn verification by the applicant stating that the information therein is true and correct and that the applicant is aware that any false statements made in the application are subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities; and(8) the signature of the applicant, which may consist of the applicant's initials.(b) Where necessary to serve the interest of justice, the court shall refer the applicant to the appropriate personnel for assistance in preparing the application.Chest. Cnty. Ct. Comm. Plea. R. 16.5