AO 115 (Rev. 01/09) Petition for a Change in Name by an Applicant for Citizenship
UNITED STATES DISTRICT COURT
for the __________ District of __________
PETITION FOR A CHANGE IN NAME BY AN APPLICANT FOR CITIZENSHIP Instructions to the Applicant for Citizenship: The Immigration and Nationality Act authorizes a United States district court to change the name of an applicant for citizenship at the same time that the court administers the oath of allegiance. The naturalization certificate will then show your new name. If you wish to change your name at the time of the naturalization ceremony, provide the following information: (1) My full name now is: (2) My place of residence is: (3) My country of birth is: (4) My date of birth is: (5) My alien registration number is: Petition to the Court: I certify that I am not seeking a change in name for any unlawful purpose, such as to avoid debt or evade law enforcement. I ask the court to change my name to: . . . . .
Date:
Petitioner’s signature
Certification of Name Change I certify that the court granted this change in name on (date) .
Date: CLERK OF COURT
Signature of Clerk or Deputy Clerk
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