Fill and Sign the In the Office of the Lieutenant Governor Form

Form A – Rev. 02/2018 Page 6 IN THE OFFICE OF THE LIEUTENANT GOVERNOR OF THE STATE OF HAWAII In the Matter of the Petition ) ) of ) ) (1) ) ) For Change of Name ) ) PETITION TO THE HONORABLE DOUGLAS S. CHIN, LIEUTENANT GOVERNOR OF THE STATE OF HAWAII: (2) COMES NOW your petitioner herein, and respectfully prays that an order be entered herein (3) changing name and in support thereof represents as follows: I. (4) That your Petitioner’s date of birth is place of birth is father’s name is (Name as shown on birth certificate) mother’s maiden name is (First) (Middle) (Surname) II. (5) That the name on your Petitioner’s birth certificate or certificate of naturalization is (First) (Middle) (Surname) Form A – Rev. 02/2018 Page 7 III. (6) That other names Petitioner is using or has used are as follows: IV. (7) That your Petitioner is a resident of the State of and Petitioner’s present address is (Residence address) V. (8) That your Petitioner: has not been convicted of a felony or a sexual offense. has been convicted of a felony. has been convicted of a sexual offense Felony or Sexual Offense Date of Conviction Disposition If Petitioner has been convicted of a felony or a sexual offense, respond to the following questions: 1. Fully explain the charges. 2. Fully explain the sentence. 3. Fully explain the terms and conditions of parole or probation. 4. Fully explain the date of final discharge of the sentence. 5. Fully explain whether there was a deferred acceptance of a guilty or no contest plea. 6. Fully explain if there was a pardon, by whom the pardon was granted. Form A – Rev. 02/2018 Page 8 VI. That this Petition is not filed for the purpose of avoiding payment of debts to creditors; your Petitioner has been and is a good law- abiding citizen and your Petitioner states that this Petition for Change of Name is not for wrong or fraudulent purposes. VII. That your Petitioner is now requesting a Change of Name to (9) WHEREFORE, your Petitioner prays that an order be entered herein Changing Petitioner’s (10) name from to DATED: Hawaii (City) (11) Petitioner (Sign name in full) STATE OF HAWAII ) ) COUNTY OF ) SS. (Honolulu, Hawaii, Maui, Kauai) (12) , being first duly sworn on oath (Name of Petitioner) deposes and says: That Petitioner is the person named herein, that Petitioner has read the foregoing Petition, knows the contents thereof, and that the same is true to the best of the Petitioner’s knowledge. (13) Petitioner (Sign name in full) Subscribed and sworn to before me this day of , 20 (Notary Stamp or Seal) Notary Public, State of Hawaii Printed Name: My Commission expires: Doc. Date: ____________ # Pages: __________ Notary Name: __________________ ___ Circuit Doc. Description: _________________________ ________________________________________ ( Stamp or seal) ________________________________________ Notary Signature Date