Consent Form For Change Of Name Page 2
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3IN THE CIRCUIT COURT OF THE
JUDICIAL CIRCUIT,
IN AND FOR
COUNTY, FLORIDA
Case No.:
Division:
IN RE: THE NAME CHANGE OF
,
Petitioner.
CONSENT FOR CHANGE OF NAME (MINOR CHILD(REN))
I, {full legal name}
, being sworn, certify that
the following information is true:
I am the birth or legal ( ) father ( ) mother of the minor child(ren) named in this case, and I give
consent for the following name changes:
Minor child(ren)’s name(s) to be changed to:
Minor child(ren)’s complete present name(s):
(1)
(1)
(2)
(2)
(3)
(3)
(4)
(4)
(5)
(5)
(6)
(6)
I understand that I am swearing or affirming under oath to the truthfulness of the claims
made in this consent and that the punishment for knowingly making a false statement includes fines
and/or imprisonment.
Dated:
Signature of Consenting Parent
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
STATE OF FLORIDA
COUNTY OF
Sworn to or affirmed and signed before me on
by
.
NOTARY PUBLIC or DEPUTY CLERK
[Print, type, or stamp commissioned name of notary or
clerk.]
Florida Supreme Court Approved Family Law Form 12.982(d), Consent for Change of Name (Minor Child(ren)) (9/00)
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