Change Of Name Judgment
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Approved for Use in Uncontested Cases Only
IN THE CIRCUIT COURT OF _________________________, MISSOURI
______________________________________________________
______________________________________________________
Case No. ____________
______________________________________________________
Division No. ____________
Petitioner(s),
Change of Name Judgment
Parties
1. Appearances (
Check all that apply)
Petitioner(s) appears in
Petitioner(s) appears by
Petitioner(s) appear by
person.
attorney.
Next Friend.
________________ appears
________________
in person.
appears by attorney.
2. The court finds that the change of name(s) would be proper and would not be detrimental to the
interests of any other person.
3. The name(s) of Petitioner(s) is/are changed as follows:
From
To
Birth Date
Change of Birth Records
4.
It is further ordered that the Division of Health and Senior Services, Bureau of Vital Statistics
for the State of Missouri alter the birth certificate(s) of Petitioner(s) to reflect this judgment. This
judgment shall be mailed by the Petitioner(s) to the Division of Health and Senior Services
It is further ordered that the State of ________________ alter the birth certificates(s) of
Petitioner(s) to reflect this judgment. This judgment shall be mailed by the Petitioner(s) to the
appropriate state of birth of Petitioner(s).
Notice
5.
Notice of the change of name(s) shall be published at least once each week for three
consecutive weeks in the following newspaper of general circulation:
________________________________________________________________________________
No notice of change of name is to be published because the petitioner is the victim of a
crime based upon domestic violence as defined in §455.200, RSMo; or the victim of child abuse
as defined in §210.110, RSMo; or the victim of abuse by a family or household member, as
defined in §455.010, RSMo.
Change of Name Judgment – Page 1 of 2
Form CAFC470-07/01/2012
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