Fill and Sign the Consent Name Change Form

IN THE COURT OF COMMON PLEAS OF ____________ COUNTY, PENNSYLVANIA IN RE: CHANGE OF NAME OF : NO. __________________ :       : a minor : : CONSENT TO NAME CHANGE I hereby declare the following: 1. My name is ______________________________ and I currently reside at ____________________________________ in the city of __________________ , in the county of ________________________ in the state of __________________ , and have so resided for a period of _____ years and ~months prior to the making of this application. 2. I am the natural father of ______________________________ minor child born on the _____ day of __________________ , ______ . 3. I consent to the Petition to Change Name of ______________________________ , a Minor Child, from ______________________________ to ______________________________ . 4. I understand the legal effect of such a change of name, and I have no objections to this court issuing an order to effect said change of name. I hereby certify that all statements made in the foregoing consent are true to the best of my knowledge and belief. DATED: __________________       Signature of Party       Printed Name       Address       City, State, and Zip Consent to Name Change Page 1 of 2       Telephone Number SUBSCRIBED AND SWORN to before me this day ______ of __________________ , 20 ______ . Notary Public My commission expires:       Type or Print Name Consent to Name Change Page 2 of 2