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