Petition
on application for change of name.
County Court, County of _________
In the Matter of the
Application of _________
for leave to assume another
name
To the County Court of the
County of _________
The petition of _________, respectfully alleges
that:
1. Petitioner resides at No. _________ street in the
city of _________, county of _________ and state of _________, and has so
resided for a period of _________ years and _________ months prior to the
making of this application.
2. Petitioner desires to assume another name than
now held by him and that the name which he proposes to assume is _________.
3. The grounds for this application for such change
of name are as follows: _________(State grounds of application in detail.).
4. Petitioner is not married and has no children.
5. Petitioner is a citizen of the United States of
America (having been duly naturalized by the _________ county on the _________
day of _________).
6. Petitioner was born at _________ on the _________
day of _________, _________ [date], and is now _________ years of age.
The name of petitioner's father is _________ and the name of petitioner's
mother is _________.
7. Petitioner, under the name by which he is now
known or under any other name he has ever used, has never been convicted of a
crime and has never been adjudicated a bankrupt.
8. There are no judgments or liens of record and no
actions pending against petitioner in any court of this state or of the United
States, or of any governmental subdivision thereof, or elsewhere, whether the
court be of record or not. There are no bankruptcy or insolvency proceedings,
voluntary or involuntary, pending against petitioner in any court whatsoever or
before any officer, person, body or board having jurisdiction thereof and
petitioner has not at any time made any assignments for the benefit of
creditors.
9. There are no claims, demands, liabilities or
obligations of any kind whatsoever on a written instrument or otherwise against
petitioner under the only name by which he has been known, which is the name
sought herein to be abandoned, and petitioner has no creditors who may be
adversely affected or prejudiced in any way by the proposed change of name.
10. [Where applicant was born in the state of
_________.] Annexed to this petition and made a part hereof is a birth
certificate of petitioner.
11. No prior application for this or other similar
relief has been made.
Wherefore petitioner prays that an order of this
court may be entered granting leave to him to assume the name of _________ in
place of that of _________ on a day to be specified therein not less than 30
days after the entry of such order, and for such other and further relief as
may be proper.
_________ [date].
_________, Petitioner
(Verification)
