Verified Petition for Name Change

PETITION FOR NAME CHANGE

IN THE COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA

CIVIL ACTION - LAW

IN RE: CHANGE OF NAME OF :

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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

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,

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: