Request For Restoration Of Former Name
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1NO. (A)____________________
________________ CIRCUIT COURT
FAMILY DIVISION _________
(B)__________________________
PETITIONER
(print name of Petitioner)
SELF-HELP FORM #4A
v.
REQUEST FOR RESTORATION OF FORMER NAME
(C)__________________________
RESPONDENT
(print name of Respondent)
* * * * * * * * *
The respondent states:
1. I, ___________________________, am the respondent in this action for dissolution of
marriage.
2. I request that the decree of dissolution of marriage restore me to my former name,
____________________________.
______________________________
SIGNATURE OF RESPONDENT
**MUST BE SIGNED IN THE PRESENCE OF A NOTARY**
COMMONWEALTH OF KENTUCKY
)
)
COUNTY OF ______________________)
Subscribed and sworn to before me by the above-named Respondent on this ______ day
of ___________________, 20____.
My commission expires: _______________________.
NOTARY PUBLIC
STATE
AT
LARGE,
KENTUCKY
Revised: 7/18/2007
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