In the _______________ Court for _____________________ County, State of _____________________ Case No.: ____________________ In Re: The Marriage of: ________________________________) and ________________________________)
REQUEST FOR NAME CHANGE UNDER PENALTY OF PERJURY I CERTIFY that I am a resident of the State of ____________________. I Hereby request my formal name change as part of these proceedings from __________________________ to _________________________, which was my former maiden name before my current marriage. ____________________________________ Petitioner’s Signature ____________________________________ Print or Type Name ____________________________________ Petitioner’s Residence Address Executed this ______ day of ___________, 200__, by __________________________ before me, personally appeared ________________________, personally known to me or produced _______________________________ as identification and who did/did not take a sworn oath. ________________________________ Signature of Notary
(Notary Seal)
Printed Name: ________________________ My Commission Expires:___________________
IF A NONLAWYER ASSISTED YOU FILL OUT THIS FORM, THEY MUST FILL IN ALL THE BLANKS BELOW: I (name of person) _____________________________, am a nonlawyer residing at (street) _______________________, (city) _____________________, (state) _____, (phone) _______ helped (name of spouse) ____________________, who is the _____ petitioner or _____ respondent, fill out this document.