Fill and Sign the Mississippi Change Name Birth Certificate Form

IN THE CHANCERY COURT OF RANKIN COUNTY, MISSISSIPPI IN THE MATTER OF THE PETITION OF ****, PETITIONER FOR CHANGE OF NAME ON BIRTH CERTIFICATE CAUSE NO. ________ MISSISSIPPI STATE BOARD OF HEALTH, RESPONDENT PETITION TO CHANGE NAME ON BIRTH CERTIFICATE COMES NOW the Petitioner, ****, who would respectfully petition the Court as follows, to-wit: 1. Petitioner, ****, is an adult resident citizen of Rankin County, Mississippi, whose current residence is in Rankin County, Mississippi, and whose current mailing address is 128 Crimm Road, Brandon, Mississippi 39042. Petitioner has been such for more than one (1) year next preceding the date of filing of this Petition; this Court has proper jurisdiction of the Petitioner and of the subject matter. 2. Petitioner was born ****, to **** and **** in Philadelphia, Mississippi. A copy of Petitioner's Birth Certificate is attached hereto as Exhibit "A". 3. Petitioner desires to change her name to "****". Petitioner has always been called "****" and the name "****" is reflected on all Petitioner's insurance papers, checking accounts, loans, school records, employment records and credit cards. 4. Petitioner was intended to be named one "****", but through error of the delivering physician in recording said name, Petitioner's Birth Certificate reflects the name "****". 5. Likewise Petitioner's father who is incorrectly identified by said Birth Certificate as one "****" was in fact born one "****" as evidenced by the Birth Certificate attached hereto as Exhibit "B". 6. Petitioner would show unto the Court that for the above reasons she desires that her Birth Certificate be changed to reflect that her name is "****" and also that the name of her father, "****", be corrected to "****" on said Birth Certificate. Petitioner would further show that such changes are right and appropriate and in accordance with the law, Miss. Code Ann. § 41-57-23 (1972), as amended, and is in the best interest of Petitioner. WHEREFORE, PREMISES CONSIDERED, Petitioner respectfully prays that this her Petition to Change Name on Birth Certificate be received and filed and that upon a final hearing of this cause the Court will enter its Order changing the Birth Certificate to reflect that Petitioner's name is "****" and to reflect that the name of her father is "****". Respectfully submitted, _________________________ **** STATE OF MISSISSIPPI COUNTY OF RANKIN PERSONALLY APPEARED before me, the undersigned authority in and for the jurisdiction aforesaid, the within named Petitioner, ****, who having been by me first duly sworn, stated upon her oath that the matters and facts contained in the above and foregoing Petition to Change Name are true and correct as therein stated. ______________________________ **** GIVEN UNDER MY HAND AND OFFICIAL SEAL, this the ___________ day of _____________, 20___. __________________________ NOTARY PUBLIC MY COMMISSION EXPIRES: _________________________ IN THE CHANCERY COURT OF RANKIN COUNTY, MISSISSIPPI IN THE MATTER OF THE PETITION OF ****, PETITIONER FOR CHANGE OF NAME CAUSE NO. ________ SUMMONS THE STATE OF MISSISSIPPI: T0: STATE BOARD OF HEALTH BUREAU OF VITAL RECORDS 2423 N. State Street Jackson, MS 39216 NOTICE TO RESPONDENT THE COMPLAINT OR PETITION WHICH IS ATTACHED TO THIS SUMMONS IS IMPORTANT AND YOU MUST TAKE IMMEDIATE ACTION TO PROTECT YOUR RIGHTS. YOU SUMMONED TO APPEAR and defend against said Complaint or Petition at ______ O'Clock ___.m. on the ______ day of ______________, 20___, in the courtroom of the Chancery Court Building at Brandon, Mississippi, and in case of your failure to appear and defend a judgment will be entered against you for the money or other things demanded in the Complaint or Petition. You are not required to file an Answer or other pleading but you may do so if you desire. Verified Petition filed when summons issued. ISSUED THIS ______________ day of _________________, 20____. **** Rankin County Chancery Clerk By: __________________________ Deputy Clerk