Fill and Sign the Name Change Questionnaire Form

Name Change Questionnaire Your full name:       Male Female Previous names you have used:       Street address:       City:       State:       Zip:       County:       Birth date:       Social Security Number:       Home phone:       Work phone:       ext.       Cell/pager:       E-mail:       I desire to change my name from       to       The reason for the proposed change of name is:       Are there any creditors or other persons who will be defrauded or adversely affected by said change of name. Yes No Do you have pending criminal charges? Yes No If yes, describe:       Have you ever been convicted of a felony? Yes No If yes, describe:       Have you been adjudicated as a juvenile delinquent for an offense that would constitute a felony if committed by an adult in this state? Yes No If yes, describe:       Are you currently on parole? Yes No Are you currently on probation? Yes No If you are on probation or parole, specify the name of the officer, the term of probation or parole, and the charge(s):       Are you currently required to register with the police or with any other governing authority in any jurisdiction? Yes No If yes, please state why:       If name change is for a minor under 18: I desire to have said child’s name changed from       to       The name given to said child at birth was       . Minor’s date and location of birth:       Male Female Relationship of the client to the minor whose name will be changed: near relative (indicate relationship):       parent other (specify):       guardian       The names and addresses of child’s living natural parents are:       If applicable, the name(s) and date(s) of death of child’s deceased natural parent(s) is/are:       Does the natural father/mother have parental rights? Yes No Is the natural father listed as the father on the birth certificate? Yes No Has the natural father acknowledged paternity or has any Court determined his paternity? Yes No Applicable only if there is no father listed on the birth certificate (check one):       is the putative father of said minor child, and his address is       and is/is not over the age of 19 years; or The identity of said child’s natural father is unknown or undisclosed. Does the natural father/mother have any contact with the child either through visitation, correspondence, telephone or otherwise? Yes No Has the natural father/mother been notified by mail? Yes No If not, why?       Has the natural father/mother indicated whether or not he/she is opposed to the proposed change of name? Yes No Does the natural father/mother support the child either by court order or otherwise? Yes No