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

AND NOW TO WIT, on this ________ day of ____________________, 200_____, the above-captioned Petition For Name Change having come before the Court for hearing; the Court having reviewed said Petition and the Court being fully advised in the premises, finds that the necessary and appropriate information has been presented to the Court including the required Certificate of Live Birth of the Petitioner necessary for a Name Change under the laws of the State of ________________________.

THE COURT FINDS the following to have been confirmed:

a)      Petitioner’s New Name:                                         ________________________________;

b)      Petitioner’s Former Name:                                     ________________________________;

c)      Petitioner’s Social Security Number:                     __________/__________/___________;

d)      Petitioner’s Address:                                              ________________, _______________;

e)      Petitioner’s Height:                                                 ____________ feet __________ inches;

f)        Petitioner’s Weight:                                                 _________________________ pounds;

g)      Petitioner’s Hair Color:                                           ________________________________;

h)      Petitioner’s Eye Color:                                            ________________________________;

i)        Petitioner’s Race:                                                    ________________________________;

j)        Petitioner’s Sex as recorded on Birth Certificate: ________________________________;

k)     Petitioner’s Date of Birth:                                       __________/__________/___________;

l)        Petitioner’s Place of Birth:                                      ___________________, ____________;

m)    Petitioner’s Hospital Location of Birth:                  ________________________________;

n)      Petitioner’s Reason for Name Change:                  ________________________________;

IT IS THEREFORE ORDERED that, with all appropriate information provided to the Court and the Court having found that a name change for the Petitioner is in properly before the Court, the Petitioner shall henceforth be known as ____________________________________ (Petitioner’s New Name).

IT IS FURTHER ORDERED BY THE COURT that the Registrar of the State of _______________ shall establish a new certificate of birth for the Petitioner as a person born in this State upon receipt by said Registrar of a notarized affidavit by a licensed physician or surgeon or appropriate osteopathic doctor stating that the Petitioner has undergone a completed sex change, by way of surgery or such comparable treatment, subject to further investigation and verification by said Registrar through the appropriate medical persons.  (Use This Paragraph In The Case Of Sex Change Only)

                                                                                    _______________________________________

Copies to:       ____________________                    (Judge of the _____________ Judicial District)

____________________

____________________                    In And For the State of __________________.

____________________

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