Fill and Sign the Comes Now the Applicant Form

FORM CC-1411 (MASTER, PAGE ONE OF TWO) 07/18 APPLICATION FOR CHANGE OF NAME (ADULT) COMMONWEALTH OF VIRGINIA VA. CODE § 8.01- 217 VIRGINIA: In the Circuit Court of the [ ] Cit y [ ] County of ........................................................................\ ............. IN RE: ........................................................................\ ...........................................................................................(APPLICA NT’S PRESENT NAME) FIRST MIDDLE LAST SUFFIX COMES NOW, the applicant, ........................................................................\ ................................................ and af ter being duly sworn states under oath as follows: 1.Applicant’s Birth Name: ........................................................................\ ............................................................. FIRST MIDDLE LAST SUFFIX 2.City or County of Residence: ........................................................................\ ....................................................... 3. Residence Address: ........................................................................\ .................................................................... STREET AD DRESS ........................................................................................................\ ................................................................ CITY STA TE ZIP CODE C OUN TR Y 4.Mailing Address: ........................................................................\ ....................................................................... IF DIFFERENT FROM RESIDENCE ADDRESS 5a. Date of Birth: ........................................................... 5b. Place of Birth: ............................................................. 6. Full Name s of Parents 6a. Full Name: ........................................................................\ ................................................................................ FIRST MIDDLE M AIDEN (IF APPLICA BLE) CURRENT LAS T SUFFIX 6b. Full Name: ........................................................................\ ................................................................................ FIRST MIDDLE M AIDEN (IF APPLICA BLE) CURRENT LAS T SUFFIX 7. Reason for name change application: [ ] Supplemental sheet attached Answer the following questions by checking appropriate “Yes” or “No” box and providing information as requested. 8.Have you ever been convicted of a fel ony? ........................................................................\ ........ [ ] Yes [ ] No 9. Are you currently incarcerated? ** ........................................................................\ ................. [ ] Yes [ ] No If yes, indicate facility name and loc a tion: ........................................................................\ ................................... If yes, indicate name(s) of court(s) where convicted : ........................................................................\ ..................... 10. Are you a probationer with any court (s)? ** ........................................................................\ ..... [ ] Yes [ ] No If ye s, in dicate court (s) name: ........................................................................\ ..................................................... ........................................................................\ ................................................................................................\ 11. Are you a person for whom registration with the Sex Offender and [ ] Yes [ ] No Crimes Against Minors Registry is required? ** If yes, indicate court (s) where conviction occurred that resulted in the requirement to regis ter : ..................................... ........................................................................\ ................................................................................................\ 12. Have you previously changed your name either by a prior application or by marriage? [ ] Yes [ ] No (If yes, attach court order or other documentation and indicate previous names): ........................................................................................................\ ................................................................ ** No a pplication of a probationer, incarcerated per son, or person for whom registration with the Sex Offender and Crimes Against Minors Registry is required shall be accepted unless the Court finds good cause exists for such application under the reasons alleged in the application for the requested change of name . Attach explanatory documentation to the application. ........................................................................\ ................................................................................................\ . ... ............................................. ........ ....... ....... ....... ....... ....... ........ ....... ....... ... FORM CC-1411 (MASTER, PAGE TWO OF TWO) 11/11 WHEREFORE, th e undersigned applicant further certifies under oath that this name change is not sought for any fraudulent purposes and will not infringe upon the rights of others, and pursuant to § 8.01- 217 of the Code of Virginia, 1950, as amended, the applicant reques ts that the Court order a change of name from: ........................................................................\ ................................................................................................\ FIRST MIDDLE LAST SUFFIX to ........................................................................\ ................................................................................................\ FIRST MIDDLE LAST S UFFIX ______________________________________________________________ APPLICANT Comm onwealth/State of .............................................................. [ ] City [ ] County of ........................................................ Subscribed and sworn to/affirmed before me this .................. day of ................................................. , 20 .................. by ........................................................................\ ........................................................................................... ....................................................... ______________________________________________________________ DATE [ ] CLERK [ ] DEPUTY CLERK [ ] NOTARY PUBLIC My commission expires ............................ Registration No. ....................................