Change Of Name - Secretary Of State, Rhode Island Page 2

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PC-8.1 (11/02, formerly SW-19)
If minor:
_______________________________________________ _______________________________________________
Father Signature
Mother Signature
Attach form PC—9.1, Waiver, if applicable.
The undersigned petitioner makes affidavit and says that the above facts are true as to the best of his/her knowledge and belief.
__________________________________________
__________________________________________
Signature of petitioner
Date
_____________________________________________________
Relationship of petitioner
_____________________________________________
Sc.
Subscribed and sworn to before me as to the truth of all of the above facts by the petitioner.
__________________________________________
__________________________________________
Notary public (please print name)
Notary public signature
DECREE
Upon hearing, it is hereby ordered and decreed:
_______________________________________________ _______________________________________________
Date
Probate Judge
Attach certified copy of the original birth certificate and BCI Report.

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