Fill and Sign the Name Change Application for Adult City of Lynchburg Form

FORM CC-1412 (REVISED 12/05) VA.CODE §§ 8.01-217, 20-121.4 ORDER FOR CHANGE OF NAME (ADULT) Case No: Commonwealth of Virginia VIRGINIA: In the CIRCUIT COURT IN RE: This day came the applicant , having filed his/her verified application requesting the change of her/her name from (FIRST MIDDLE LAST SUFFIX) to (FIRST MIDDLE LAST SUFFIX) Additional former name(s) of applicant: The applicant’s address is: [ ] The Court finds that the applicant has been convicted of a felony and is [ ] presently incarcerated [ ] a probationer of the Court But good cause exists for the application in that The Court finds that [ ] the application complies with the requirements of subsection B of Virginia Code § 8.01-217, [ ] A motion was made pursuant to Virginia Code § 20-121.4 incident to divorce, and that the change of name is not sought for any fraudulent purpose, and that the change of name would not otherwise infringe upon the rights of others. Accordingly, it is ADJUDGED and ORDERED that the name of is hereby changed, effective this date, to The Clerk of this Court shall forthwith spread this Order upon the current deed book, indexing the order in the names of and [ ] The Clerk of this Court shall further transmit a certified copy of this Order and the Petition to the State Re gistrar of Vital Records and to the Central Criminal Records Exchange. [ ] This change of name is granted incident to a divorce and the clerk shall not transmit any copy of this Order to the Registra r of Vital Records or to the Central Criminal Records Exchange. [ ] Public recording of the name change would pose a serious threat to the health or safety of the Petitioner/Petitioner’s family and the record of this cause is hereby ORDERED sealed. The Clerk shall not spread or index this Order and shall not transmit any copy of this Order to the Registrar of Vital Records or to the Central Criminal Records Exchange. [ ] The petition for change of name is hereby denied and this cause is dismissed. Entered this .............. day of ....................................................................... ___________________________________________________ JUDGE