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IN THE DISTRICT COURT FOR _______________ STATE, IN AND FOR _______________ COUNTY

______________________________
(Petitioner’s Name)

______________________________

______________________________
(Petitioner’s Address)

______________________________
(Social Security Number)

CASE NO. ____________________

                   CERTIFIED
                PETITION FOR
            CHANGE OF NAME

COMES NOW the Petitioner in the above-captioned matter and for this Petition for Change of Name states the following:

The current and proper name of the Petitioner is ___________________________________.

The current State of residence for the Petitioner is ____________________ and the current address of the Petitioner is ______________________________________ in the City of _________________________, and the Zip Code of _______________. This residence in the State of ____________________ is in the County of ____________________.

A certified copy of the birth certificate of the Petitioner is attached to this Petition.

The vital statistics for the Petitioner are as follows:

a.   Social Security Number                      _______/_______/______;
b.   Height                                                 _____________________;
c.       Weight                                                _____________________;
d.   Eye Color                                            _____________________;
e.   Race                                                    _____________________;
f.        Sex as recorded on Birth Certificate _____________________;
g.   Date of Birth                                       __________/_____/_____;
h.   Place of Birth                                      ____________, ________;
i.        Hospital of Birth                                 _____________________;
j.    Current Marital Status                       _____________________;
k.   Names of Children, if any                   _____________________, _____________________, _____________________,
_____________________, _____________________, _____________________, _____________________;
l.        Description of Property Owned         __________________________________________________________________ __________________________________________________________________________________________________.

Additional residences during the past five (5) years, other than the residence shown in paragraph two (2) above, are as follows: ___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________.

The information contained in the foregoing paragraphs is true, correct, complete, and without omission.

The reason for this Petition for Change of Name is: (insert specific reason, such as “change of gender” or “return to maiden name”): ____________________________________________________________________________________________________________.

8. The Name of which the Petitioner wishes to be known is: ______________________________________.

9. There is no known reason to the Petitioner why a Name Change should not be granted in this matter.

10. This Petition is for the specific reasons set forth herein and is made in good faith pursuant to said representations.

WHEREFORE, the Petitioner respectfully prays that the Court grant a Name Change pursuant to the foregoing Petition.

_________________________ (Name of Attorney or Petitioner)

________________________ (Petitioner’s Address)

_________________________ (Petitioner’s City & State)

_________________________ (Petitioner’s Phone Number)

AFFIDAVIT OF CERTIFICATION

I, ________________________________ (Name of Petitioner), being first duly sworn on oath depose and state that I am the Petitioner, as above-captioned, and I have read the foregoing Petition for Change of Name, including each and every paragraph, and hereby state that the Petition and its’ contents are true and correct in every respect. I am aware of the ramifications of perjury in the event any of the foregoing statements are determined to be untrue and, accordingly, I hereby verify that the contents are correctly and completely stated.

__________________________________
(Petitioner’s Signature)

STATE OF ____________________

COUNTY OF ____________________

The foregoing individual, _______________________________ (Name of Petitioner), personally appeared before me, a Notary Public in and for the County of _______________ and the State of _______________, on this _____ day of _______________, 20____ and swore or affirmed under oath that the foregoing statements contained within the Petition are true and correct as said Petitioner verily believes.

__________________________________

(Notary Public for _________________)

My commission expires on the ____ day of _______________, 20____.

The form above is an example of how a typical Checklist form may be completed.

The name of the testator is indicated. This should be the testator's full name.
The date of the testator's will is noted because this Checklist is a guideline.
The full names of the witnesses should be set forth, including addresses if known.
The name of the Notary Public since the notary in many states will serve as a substitute witness to the individual witnesses.
The place of signing verifies the identity of the location where the will was signed. A full address should be indicated.
The full name of the testator is provided.
The age of the testator should be set forth.
The date of birth of the testator is indicated for past record verification.
The complete address of the testator should be set forth.
The name, address, and phone number of the testator's spouse should be indicated.
The names of any children of the testator should be set forth. In the instance where there are several children, they should all be identified with full names, addresses, and phone numbers.
The identity of the parents of the testator should be set forth with particularity.
Any brothers and sisters of the testator should be identified with names, addresses, and phone numbers.
Any additional relatives of the testator should be set forth. The relationship of the relatives to the testator should be indicated.
If the executor is related to the testator, the relationship should be identified.
The personal property of the decedent should be identified. In this case, a bank account was identified.
Any additional personal property, such as other accounts, may be identified.
The listing of the certificates should be set forth.
The name of a stockbroker, along with the address and phone number of the stockbroker.
The full number of shares should be set forth.
The valuation for the stock should be set forth, including a particular time for the valuation.
Information regarding any bonds held by the testator should be provided.
The amount of any bonds should be set forth. Generally, and face value is noted.
If the bonds were cashed, it should be indicated. The amount received for the bonds should also be included.
Any jewelry should be identified.
The value of the jewelry should be provided.
Automobiles should be identified with particularity.
The year of each vehicle should be noted.
The license of each vehicle should be provided, along with the state in which the vehicle is licensed.
The value of each vehicle should be indicated.
Any equipment owned by the testator should be identified.
The location of the equipment by address or by identity of the individual who may have possession of the equipment.
The value of the equipment should be set forth.
Any commodities owned by the testator should be identified.
The amount of the commodities should be indicated.
The location of the commodities should be set forth with as much particularity as possible.
Due to the fluctuation of commodities, the value in most cases would be the value at the time of death.
The identity of any livestock.
The location of any livestock should be set forth with particularity.
The value of the livestock should be provided.
The address of the residence of the testator should be provided.
The legal description of the property, if available, should be set forth.
The value of the property should be indicated.
Any other real estate owned by the testator should be noted.
The legal description of other real estate should be set forth.
The value of the real estate should be noted.
The full name of the executor should be set forth.
The full address of the executor should be provided.
The amount of bond, if bond is required, should be noted.
The name of the bonding company should be provided.
The address of the bonding company.
The phone number of the bonding company.
The name of the attorney.
The address of the attorney.
The phone number of the attorney
The name of the court where the probate occurs.
The street address of the court.
The state in which the court is located.
The identity of any creditors.
The address of any creditors.
The number of accounts and any amounts that may be due.
The names of any care providers.
The addresses of any care providers.
The phone numbers of any care providers.
The amounts due to the decedent which may not have been identified in the earlier part of this Checklist. This form, or a similar one, is generally used by attorneys during the initial conference and may be somewhat dated. Consequently, this section usually serves as a catchall when certain items have not been set forth.
The address of the individual completing this form.
The phone number of the individual completing this form.

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This is not a substitute for legal advice. An attorney must be consulted.