Fill and Sign the In Re Change of Form

Pag e 1 of 2 Form PS -34282 -5 Approved by State Court Administration 12/10 STATE OF INDIANA ) IN THE CIRCUIT COURT ) SS: COUNTY OF ) CASE NO. IN RE CHANGE OF ) NAME OF MINOR: ) ) ) ) Petitio ner. ) VERIFIED PETITION FOR CHANGE OF NAME OF MINOR Petitioner, , pro se, respectfully petitions this court to change the name of the above -noted child. In support of this Petition, Petitioner states as follows: 1. Petition er is the father/mother/guardian of the child whose name is sought to be changed. 2. The written consent of the non -petitioning parent or guardian for the name change of the minor child is filed with this Petition (not required under I.C. 31 -19 -9). 3. That the child’s current name is: . 4. That the child’s date of birth is: . 5. That the child’s mailing address is: And, if different, the child’s residential address is: 6. That the child’s Indiana driver’s license number/Indiana identification card number is ; and I will bring the child’s Indiana driver’s license or identification card to the Change of Name Hearing for verification. 7. The following is a list of all of the previous names of the child: . 8. That the child (does) (does not) hold a valid United States passport. Proof that the child is a United States citizen is . I will bring this document to the Change of Name Hearing for verification. Pag e 2 of 2 Form PS -34282 -5 Approved by State Court Administration 12/10 9. That the following judgments of criminal conviction of a felony under the laws of any state or the United States have been entered against the child, or I have st ated immediately below that the child does not have any felony convictions: . 10. That changing the child’s name is not an effort to defraud any of the child’s creditors. 11. That notice of the request for name change has been published in a local publication as required by law and will be brought to the Change of Name Hearing. 12. That the child is not confined to a Department of correction facility or a sex or violent offender who is required to r egister under I.C. 11 -8-8. 13. That pursuant to Indiana Code 34 -28 -2-1, I petition this court to change the child’s name. Pursuant to Indiana Code 34 -28 -2-2 (b), the reason the change of the child’s name is requested is: . 14. That I request that the child’s name be changed to . 15. The non -petitioning parent or guardian of the Minor child has been served with a copy of this Petition as required by the Indiana Trial rules. 16. I request this Court to set a hearing to consider the Petition for Change of Name of Minor Child . WHEREFORE, I respectfully request that this Court grant this Petition for Name Change of a Minor, and for all other just and proper relief. I affirm u nder the penalties of perjury that the foregoing representations are true. Signature (Parent)(Guardian) (Parent)(Guardian) Printed Name Mailing Address Town, State and Zip C ode Telephone Number, with Area Code CERTIFICATE OF SERVICE I certify that I sent a copy of this Petition by first class mail to the opposing party on . Signature (Parent) (Guardian)