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

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

1. The current and proper name of the Petitioner is ___________________________________.

2. 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 ____________________.

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

4. 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         __________________________________________________________________ __________________________________________________________________________________________________.  

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

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

    7.   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 _______________, 200____ 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 _______________, 200____.

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