Fill and Sign the County as Shown above and Have Done so Form

Name Change: Petition, p 1 Approved: November 19, 2004 (Name) (Address) (City) (Telephone) DISTRICT COURT, COUNTY, UTAH COURT’S ADDRESS: IN THE MATTER OF THE NAME CHANGE OF: , PETITION FOR NAME CHANGE (petitioner’s name) Petitioner. Case No. ____________________ Judge _______________________ Petitioner states as follows: 1. I live in County, as shown above, and have done so name of county) for more than one year. 2. My full and correct name is . (your current legal name) 3. I ask the Court to change my name to . (your proposed new name) 4. I want to change my name because (reasons for changing your name) Name Change: Petition, p 2 Approved: November 19, 2004 5. I do not know any reason why I should not be allowed to change my name. 6. Except for this petition, I am not presently involved in any court actions or proceedings. 7. I am not presently on probation or parole. 8. I am not barred as a sex offender from obtaining a name change, under the provisions of Section 77-27-21.5(17). I have attached a Certification Regarding Sex Offender Registry completed by Utah’s Department of Corrections, showing that there were no search results for my name. 9. I am not changing my name to avoid creditors or anyone else with a claim against me. 10. My name change will not affect any right, title or interest of anyone else, and I do not know anyone else who should be notified of this petition. DATED: ____________________________ Petitioner NOTARY CLAUSE , Petitioner, is personally known to me or presented satisfactory proof of identity to me. After being sworn and while under oath, Petitioner stated that he or she was acting voluntarily, had read and understood the preceding document, and that the contents were true. Petitioner then signed the document in my presence. Signed on , 20    . X_________________________________________ Notary Public/Court Clerk (Notary Seal)