Fill and Sign the Filing Proof Form

STATE OF INDIANA ) IN THE       CIRCUIT COURT ) SS: COUNTY OF       ) CASE NO.       IN RE CHANGE OF ) NAME OF MINOR: )       ) )       ) Petitioner. ) NOTICE OF FILING PROOF OF PUBLICATION Petitioner,       _____________________________________, pro se, states as follows: 1. I have given notice of the Petition for Change of Name of Minor Child, pursuant to Indiana Code 34-28-2-3. 2. Notice was given by three (3) weekly publications in a newspaper of general circulation published (in the county in which the petition is filed in court)(in the nearest adjacent county because no newspaper is published in the county in which the petition is filed). 3. The first notice was published not more than seven (7) days after the date the Petition to Change Name of Minor Child was filed. 4. The published notice included: A. The name of the petitioner. B. The name of the minor child whose name is to be changed. C. The new name desired. D. The name of the court in which the action is pending and cause number. E. The date on which the petition was filed. F. The date, time, and location of the hearing. G. A statement that any person has the right to appear at the hearing and to file objections. 5. I have attached a copy of the published notice herein as Exhibit A. Page 1 of 2 Form PS-34282-8 Approved by State Court Administration 12/10 6. The attached notice has been verified by the affidavit of a disinterested person. 7. More than thirty (30) days have passed since the final required publication of notice. WHEREFORE, I affirm under the penalties of perjury that the foregoing representations are true to the best of my knowledge and belief. Signature (Parent)(Guardian)       (Parent) (Guardian) Printed Name       Mailing Address       Town, State and Zip Code       Telephone Number, with Area Code Page 2 of 2 Form PS-34282-8 Approved by State Court Administration 12/10