Fill and Sign the Petition Change Name 497324764 Form

IN THE COURT OF COMMON PLEAS OF __________________ COUNTY, PENNSYLVANIA CIVIL ACTION - LAW IN RE: CHANGE OF NAME OF : :       :       :       : NO. _______________       :       :       : : VERIFIED PETITION FOR NAME CHANGE The Petitioner , ____________________________________ , requests that this Court order a change of name for them and their minor children , and in support thereof represents as follows: 1. Petitioner ______________________________ is an adult individual, whose date of birth is ________________________ , and who presently resides at ______________________________ , in the County of __________________ . 2. Petitioner ______________________________ is an adult individual, whose date of birth is ________________________ , and who presently resides at ______________________________ , in the County of __________________ . 3. Petitioner , ______________________________ , also request the Court to change the names of the following minor child who is residing with Petitioner at the above address: Name Date of Birth SSN                                                                         Petition for Name Change Page 1 of 3 3. Petitioner desires this change of name for the following reason(s):                   4. Petitioner ______________________________ , whose social security number is __________________ and Petitioner ______________________________ , whose social security number is __________________ , is a citizen of the United States of America. 5. There are no judgments or decrees pending against either Petitioner . 6. WHEREFORE, Petitioner respectfully requests that this Court enter an Order changing the name of Petitioners : From To                         7. WHEREFORE, Petitioner respectfully request that this Court enter an order changing the name of minor child : From To                                                 Respectfully submitted, Petitioner       Type or Print Name       Telephone Number Petitioner Petition for Name Change Page 2 of 3       Type or Print Name       Telephone Number VERIFICATION I ,       , verify that the statements made in this petition are true and correct to the best of my knowledge, information and belief. I understand that the statements herein are made subject to the penalties of 18 Pa. C.S. §4904 relating to un-sworn falsification to authorities. Date: ______________________ ______________________________ Petitioner - Signature ______________________________ Petitioner - Signature Petition for Name Change Page 3 of 3