Fill and Sign the Name Change Certificate Form

STATE OF SOUTH CAROLINA ) IN THE FAMILY COURT OF THE )       JUDICIAL CIRCUIT COUNTY OF       ) ) ) EX PARTE: ) PETITION FOR NAME CHANGE ) AND AMENDMENT OF BIRTH       ) CERTIFICATE Plaintiff ) Docket No.       1. The Plaintiff was born in       County, State of       on       (date), and presently resides in the County of       , State of South Carolina. 2. The Plaintiff’s legal name is       . 3. The Plaintiff desires to change his/her name to       . 4. The Plaintiff desires the name for the following reasons:             5. The Plaintiff has no intention to defraud anyone or to avoid creditors by virtue of the name change. 6. Petitioner has previously provided the court, or has attached hereto, the following: a. The results of a fingerprint and criminal background check performed by the State Law Enforcement Division, Petition for Name Change Page 1 of 2 b. An affidavit as to whether Petitioner is under an order to pay child support or alimony, c. A statement from State Law Enforcement Division stating whether Petitioner is on the sexual offender registry, and d. A statement from the Department of Social Services as to whether Petitioner is on the Central Registry on Child Abuse and Neglect. The Plaintiff respectfully requests this Court, pursuant to Section 15-49-10 of the South Carolina Code Ann. (1976), to change his/her name from       to       . Plaintiff’s Address: ____________________________________ Plaintiff       Dated: __________________       , South Carolina       Telephone No.       STATE OF SOUTH CAROLINA ) ) VERIFICATION COUNTY OF       )       , being duly sworn, says that (he)/(she) is the Plaintiff herein, and that (he)/(she) has read the foregoing Petition and knows the contents thereof; that the same is true of (his) / (her) own knowledge, except as to matters therein stated to be alleged on information and belief; and to those matters (he) / (she) believes them to be true. SWORN to and Subscribed before me ) ) This ______ day of ____________, 20___. ) ______________________________ ) Signature of Petitioner ______________________________________ ) Petition for Name Change Page 2 of 2 Notary Public for South Carolina ) My Commission expires ) Petition for Name Change Page 3 of 2