Fill and Sign the Mississippi Name Change Form

IN THE CHANCERY COURT OF THE ________ JUDICIAL DISTRICT OF ____________ COUNTY, MISSISSIPPI ____________________ PLAINTIFF VS. CAUSE NO. _____________ ____________________ DEFENDANT ORDER GRANTING NAME CHANGE This day this cause of action came on for hearing upon the Amended Petition for Name Change filed herein by ________________________ , and the Court, after considering said Petition, and noting that the __________ State Registrar of Vital Records has no objection thereto, hereby finds as follows: 1. Petitioner ____________________________ is an adult resident citizen of the _______ Judicial District of _________ County, Mississippi. 2. The court has subject matter jurisdiction over this action pursuant to Miss. Code Ann. ' 93-17-1, and has reviewed the Petition and other pleadings filed herein. 3. As reflected by the Petitioner = s Certificate of Live Birth, attached as Exhibit __ to the Petition, she was born in _____________________________________, on __________ _____ . Said certificate reflects ___________________________ as the Petitioner = s natural mother and __________________________ as the Petitioner = s natural father. 4. The Court finds that Petitioner has been estranged from her birth father, _________ ____________ , for some __________ ( ) years, having had only instance of contact with him (for approximately ______ days) during the Petitioner = s entire life. #41537 5. The Court further finds that ____________________________ is the Petitioner = s natural mother = s maiden name. 6. The Court recognizes that Petitioner seeks to change her birth name ____________ __________ to _________________________ to take on and adopt her natural mother = s maiden name. 7. The court finds that the Defendant may be served at ___________________________ ___________________________. 8. Petitioner = s request is well-taken and shall be granted. IT IS, THEREFORE, ORDERED, ADJUDGED AND DECREED that the Petitioner = s name be, and hereby is, changed to ___________________________ , and the __________ State Registrar of Vital Records is hereby ordered to correct any record regarding __________ to reflect her new name, ________________________ , in accordance with Miss. Code Ann. ' 93-17-1. SO ORDERED, ADJUDGED AND DECREED this the _____ day of __________ _____. __________________________________________ CHANCELLOR Prepared by: ____________________ ____________________ ____________________ ____________________ Telephone No.: ____________________ #41537