Fill and Sign the Being Duly Sworn Testifies that Heshe Form

Proof of Publication Page 1 of 2 IN THE COURT OF COMMON PLEAS OF __________________ COUNTY, PENNSYLVANIA CIVIL ACTION - LAW IN RE: CHANGE OF NAME OF : : : : :NO. _______________ : : : PROOF OF PUBLICATION County of ____________________________________________________________ being duly sworn, testifies that he/sheis ________________________ of the ________________________, a newspaper published at ______________________________ and circulated in the above county and that he/she is familiar with the facts and that the notice, a copy of which is attached, was published in said newspaper once thirty (30) days prior to the time fixed for the hearing thereof, and that the publications were made on the:____________ day of ________________________ , 20______Dated: ________________________ ____________________________________ SignatureCommonwealth of Pennsylvania County of __________________On this ______ day of __________________ , ____________, before me a notary public in and for the Commonwealth of Pennsylvania, the undersigned officer, personally appeared , known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he/she executed the same for the purposes therein contained. Proof of Publication Page 2 of 2 In witness whereof, I hereunto set my hand and official seal.Notary PublicMy commission expires: Type or Print Name