Form Pc 122 - Petition Form To Change Name

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Pc 122
STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Unit
Docket No.____________
In re ____________________________________________ of _______________________________
PETITION OF ADULT TO CHANGE NAME
 
The undersigned petitioner represents as follows: 
That I was born at ________________________ on _______________; 
 
 
         
town/city and state                                                        date of birth 
 
That I have the following minor children, who were born in the following locations: 
 
Name of child 
 
 
town/city and state   
 
 
date of birth 
 
______________________________________________________________________________________________________________________________ 
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________ 
 
That I am married to __________________________________ of ______________________________ 
 
That the name I wish to be known by is: ___________________________________________________ 
 
That I understand that by filing this petition I consent to the court’s requesting the Department of 
Public Safety to determine whether the petitioner’s name appears on the sex offender registry 
established by 13 V.S.A. § 5402 and to disclosure of the information to the court by the department; 
and I understand that, if the department reports that the petitioner’s name appears on the registry, 
the court shall permit the department to appear on the question whether there is a compelling reason 
for granting the petition. 
 
 
Date: __________________   
Signed: _____________________________________,Petitioner 
 
 
 
 
 
Print Name: _________________________________ 
 
 
 
 
 
Mailing Address: _____________________________ 
 
 
 
 
 
___________________________________________ 
 
 
 
 
 
Telephone/email:_____________________________
At __________________________ on this ______ day of ___________________, 20____, 
_________________________________________ personally appeared before me and acknowledged 
this instrument by him/her signed, to be his/her free act and deed. 
 
 
 
 
 
 
 
____________________________________________ 
Judge/Register 
10/11 SML 

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