Form Dl-101 - Affidavit For Name Change printable pdf download

DL-101 (Rev. 8/08)

CUSTOMER NO.____________

AFFIDAVIT FOR NAME CHANGE

I, ____________________________________________________________, being first duly sworn or affirmed, depose and state:

1. That my present full legal name (including first, middle and last) is:

_________________________________________________________________________________________________________

2. That my name, as stated on my birth certificate is: _______________________________________________________________

3. That I changed my legal name from: ______________________ To: _____________________ on _____ / ____ / __________

4. That I was born on, ____ /______ / _______ in the City of _______________________________________________________

County of __________________________________ State of ___________________________________________________ .

5. That I presently reside at ___________________________________________________________________________________

(street address, city, state, zip code)

I have resided at this location since __________________ My mailing address is: ____________________________________

_______________________________________________________________________________________________________

(list only if different than residence address)

6. That my natural/adoptive (circle one) mother’s full name, including any middle or maiden name, is

_______________________________________________________________________________________________________

7. That my natural/adoptive (circle one) father’s full name is: ________________________________________________________

8. That during the last ten years, I have used or have been addressed by the following names in the jurisdiction(s) and on the dates

listed below:

Name __________________________________________________________________________________________________

Jurisdiction ___________________________________________________________________date ______/ ______/ ________

Name __________________________________________________________________________________________________

Jurisdiction ___________________________________________________________________date ______/ ______/ ________

Name __________________________________________________________________________________________________

Jurisdiction ___________________________________________________________________date ______/ ______/ ________

9. That the following is a complete list of locations where I have resided during the last ten years and the length of each residency.

Address: ____________________________________________ City: _________________________ State: _______________

Length of residency: From: ____________________________ To: ________________________________________________

Address: ____________________________________________ City: _________________________ State: _______________

Length of residency: From: ____________________________ To: ________________________________________________

Address: ____________________________________________ City: _________________________ State: _______________

Length of residency: From: ____________________________ To: ________________________________________________

Form Dl-101 - Affidavit For Name Change