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Fill and Sign the Dc 6111 Form

Fill and Sign the Dc 6111 Form

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Page 1 of 3 Petition for Name Change of a Minor Child DC 6:11(1) Rev. 05/ 15 IN THE DISTRICT COURT OF ________________ COUNTY, NEBRASKA (c ounty where Petition filed) IN RE NAME CHANGE OF CASE No.___________________ (case number assigned by Clerk of Court) ______________________________ (minor chil d(ren)’s current full name(s)) ______________________________ ______________________________ ______________________________, Minor Child(ren), By Parent or Guardian 3(7I7I21 )25 1$0( CH$1*( 2) $ 0I125 CHILD 25 CHILD5(1 ______________________________. (your full name) I, ____ ___________________________, on behalf of ____________________ (your full name) ____________________________________________________________________ __ (minor child(ren)’s current full name(s)) ______________________________________________________________________ minor child(ren), and without the assistance of an attorney, ask this Court for a name change for the minor child(ren). In support of t his Petition, I state that the following items are true: 1. My address is _____________________________________________, (your present street address) _____________________, ____________________County, Nebraska. (city where you live ) (county where you live) P E TITION FOR NAME CHANGE OF A MINOR CHILD Nebraska State Court Form DC 6:11(1) Rev. 05/15 2. The minor child(ren)’s current name (s) is /are _______________________ _____________________________________________________________________. (minor child(ren)’s current full name(s)) ______________________________________________________________________ 3. The minor child(ren) ’s current address is __________________________, (minor child(ren)’s present street address) ____________________, ___________________ County, Nebraska. (city where minor child(ren) live(s)) (county where minor child(ren) live(s)) 4. The minor child(ren)’s date(s) of birth is/are provided on the Confidential Party Information Form (page 4 of the Petition for Name Change). 5. My relationship to the minor child(ren) is ___ _______________________. (mother/father) 6. The minor child(ren) and I have been residents of _ ________________ __ ( county where you and minor child(ren) live) County, Nebraska for more than one year prior to the filing of this Petition. 7. I desire that the court change the name (s) of _______________________ ______________________________________________________________________ (minor child(ren)’s current full name(s)) _____________________________________________________________________, minor child(ren), to ______________________________________________________ (minor child(ren)’s preferred new full name(s)) ______________________________________________________________________ _____________________________________________________________________. 8. The other parent of the minor child(ren) is _________________________ ___________________________________________________. (minor child(ren)’s other parent’s full name) 9. I desire to change the name (s) of the minor child(ren) , _______________ ______________________________________________________________________ (minor child(ren)’s current full name(s)) ______________________________________________________________________ Page 2 of 3 Petition for Name Change of a Minor Child DC 6:11(1) Rev. 05/ 1 5 for the following reason(s): ________________________________________________ _________________________________________________________________________________________________________ (list here why you desire to change the minor child(ren) ’s name(s)) ________________________________________________________________________________________________________ ________________________________________________________________________________________________________. I request the court set this matter for hearing, and that upon such hearing, enter an order changing the name (s) of the minor child(ren) from _ _____________________________________________________________________ (minor child(ren)’s current full name(s)) ______________________________________________________________________ to _ ____ _____________________________________________________________ __ (minor child(ren) ’s preferred new full name(s)) _____________________________________________________________________. Date Petitioner ’s Signature (your signature) Your Full Name Your Full Street Address/P.O. Box City/State/ZIP C ode Phone E-mail Address Page 3 of 3 Petition for Name Change of a Minor Child DC 6:11(1) Rev. 05/ 15 Page 1 of 1 I N THE DISTRICT COURT OF ________________ COUNTY, NEBRASKA (county where Petition filed) THIS DOCUMENT IS CONFIDENTIAL AND SHALL NOT BE MADE PART OF THE COURT FILE OR PROVIDED TO THE PUBLIC PURSUANT TO NEB. CT. R. § 6-1521. IN RE NAME CHANGE OF CASE No.___________________ (case number assigned by Clerk of Court) __ ___________________. CONFIDENTIAL PARTY (minor child(ren)’s current full name(s)) INFORMATION FORM _____________________ __ ___________________ __ ___________________ Name G ender Birth Date Children: (child’s current full name) (chi ld’s current full name) (child’s current full name) (child’s current full name) Page 1 of 1 Confidential Information for Petition for Name Change of a Minor Child DC 6:11(1) Rev. 05/15 C ONFIDENTIAL PARTY IN FO RM ATION FORM - MINOR NA ME CHANGE N ebraska State Court Form DC 6:1 1(1) Rev. 05/1 5

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