Petition For Change Of Name Page 2

3. Select one of the following:

I have never registered as a sexual offender; OR

I am or have previously been registered as a sexual offender under the following name:

Full Name as Registered

4. I am requesting this change of name because:

5. I wish to change my name to:

New Name

6. I hereby certify that the above change of name is not requested for any illegal or

fraudulent purposes.

WHEREFORE, I respectfully request that the Court pass an Order changing my name

from

Current Name

New Name

, solemnly affirm under the penalties of

Your Current Name

perjury, that the contents of the foregoing paper are true to the best of my knowledge,

information and belief.

Date

Your Signature

Your Name - Printed

Address

City, State, Zip

Telephone

Reset

Page 2 of 2

DR 60 (Rev. 9/2005)

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Parent category: Legal