Fill and Sign the Consent to Name Change Form

Consent to Name ChangePage 1 of 2 IN THE COURT OF COMMON PLEAS OF __________________ COUNTY, PENNSYLVANIA CIVIL ACTION - LAW IN RE: CHANGE OF NAME OF : NO. __________________ : : a minor : : : 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 __________________, ______. I am also 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 ________________________. I also 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. /// /// /// /// /// /// /// Consent to Name ChangePage 2 of 2 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 Telephone Number SUBSCRIBED AND SWORN to before me this day ______ of __________________, 20______. Notary Public My commission expires: Type or Print Name