Fill and Sign the Mississippi Name Birth Certificate Form

IN THE CHANCERY COURT OF ____________ 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 ORDER AUTHORIZING CHANGE OF NAME ON BIRTH CERTIFICATE THIS CAUSE came on for hearing this day on the Petition of ________________________ to Change Name on Birth Certificate, and the Court being fully advised in the matter and finding that it has jurisdiction of the parties and of the subject matter, further finds as follows: 1. That Petitioner, ________________________ is an adult resident citizens of ____________ County, Mississippi whose current residence is ________________________. 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. That Petitioner was born ________________________ to ________________________ in ____________ County, Mississippi. A copy of the Birth Certificate was attached to the Verified Petition filed herein. 3. That Petitioner desires to have the name on her Birth Certificate changed to "________________________" which is reflected on all Petitioner's insurance papers, checking accounts, loans, school records, employment records and credit cards. 4. That Petitioner was intended to be named ________________________, but through error of the delivering physician in recording said name, Petitioner's Birth Certificate reflects the name "________________________". 5. That 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 to the Verified Petition. 6. That Petitioner has shown 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 has further shown that such changes are right and appropriate and in accordance with the law, Miss. Code Ann. Sec. 41-57-23 (1972), as amended, and is in the best interest of Petitioner. IT IS, THEREFORE, ORDERED AND ADJUDGED that it is right and appropriate and in accordance with the law, Miss. Code Ann. Sec. 41-57-23, that the name on Petitioner's Birth Certificate be changed to "________________________" and also that the name of her father on said Birth Certificate be changed to "________________________." IT IS FURTHER ORDERED AND ADJUDGED that the Department of Vital Statistics for the State of Mississippi is charged with changing the Birth Certificate and other records of "________________________" to "________________________" and the name of "________________________" to "________________________" as set forth herein. SO ORDERED AND ADJUDGED this the ____ day of ____________, 20_____. ______________________________ CHANCELLOR PREPARED AND PRESENTED BY: ____________________________________ ____________________________________ ____________________________________ ____________________________________