Petition on application for change of name

August 8, 2011

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


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