Fill and Sign the Petition for Change of Name Missouri Courts Mogov Form

Petition for Change of Name (For Adult Individual) Page 1 of 4 Form CAFC40 1 04/2016 This form is available for free at www .selfrepresent. mo.gov IN THE CIRCUIT COURT OF , MISSOURI (Coun ty wher e cour t is loca ted . City of St. Louis is considered a county. ) In re : (First Name ) (Middle Name ) (Last Name ) (Jr./Sr./III) Petitioner (Enter your full legal name above) Case No. ( Will be assigned when case is filed ) Division No. ( Will be assigned when case is filed ) Petition for Change of Name (For Adult Individual ) Your Information (You are the “ Petitioner” in this case) 1. My current full legal name is: (First Name) (Middle Name) (Last Name) (Jr./Sr./III) 2. I want to change my name to: (First Name) (Middle Name) (Last Name) (Jr./Sr./III) 3. Check one of the two boxes. This is the first petition I have filed in this case. (Original Petition) This is the second petition I have filed in this case. 4. My mailing address is : (Street) (City) (State) (Zip) (Telephone Number with Area C ode) (E-m ail Address - Optional ) 5. My parent’s full legal name is: (First Name) (Middle Name) (Maiden Name - if applicable) (Last Name) (Jr./Sr./III) 6. My other parent’s ( father or mother) full legal name is: (First Name) (Middle Name) (Maiden Name - if applicable) (Last Name) (Jr./Sr./III) 7. My husband’s or wife’s full legal name is: (First Name) (Middle Name) (Last Name) (Jr./Sr./III) Petition for Change of Name (For Adult Individual) Page 2 of 4 Form CAFC40 1 04/2016 This form is available for free at www .selfrepresent. mo.gov 8 . My birth date is : (mm/dd/yyyy) 9 . My place of birth is: (City) (State) (Country) 10 .The change of my name would not be detrimental to any other person. 11 . I want to change my name because: 12 . I reside in t he United States another country , which is : 13 .I reside in the State of . 14 .I res ide in the County of . 15 .Check one of the two boxes. My name has never been changed . My name has previously been changed as follows: 16. Check all boxes that apply. I am the victim of a crime based upon domestic violence as defined in §455.010 , RSMo. I am the victim of child abuse as defined in §210.110, RSMo. I am the victim of abuse by a family or household member as defined in §455.010, RSMo. None of the above. 17 .Check one of the two boxes. There are no unsatisfied money judgments against me. There are unsatisfied money judgments against me in the following cases: State the name and number of the case in which the judgment was entered and the court in which the judgment was entered. State the name and number of the case in which the judgment was entered and the court in which the judgment was entered. Petition for Change of Name (For Adult Individual) Page 3 of 4 Form CAFC40 1 04/2016 This form is available for free at www .selfrepresent. mo.gov 18 .Check one of the two boxes.There are no cases requesting money pending against me. The following cases in which money is requested are pending against me: State the name and number of the case and the court in which it is pending. Children’s Information 19 .I have child(ren) who is/are listed below. Enter the number of children above. Enter each child’s full name below as it appears on the birth certificate . Also state the age and address of each child. If you have more than six children, attach an additional page. a. (F irst Name ) (Middle Name ) (Las t Name ) (Jr./Sr ./III) (Child’s Age) (Street) (City) (State) (Zip) b. (First Name ) (Middle Name ) (Las t Name ) (Jr./Sr ./III) (Child’s Age) (Street) (City) (State) (Zip) c. (F irst Name ) (Middle Name ) (Las t Name ) (Jr./Sr ./III) (Child’s Age) (Street) (City) (State) (Zip) d. (First Name ) (Middle Name ) (Las t Name ) (Jr./Sr ./III) (Child’s Age) (Street) (City) (State) (Zip) e. (First Name ) (Middle Name ) (Las t Name ) (Jr./Sr ./III) (Child’s Age) (Street) (City) (State) (Zip) f. (First Name ) (Middle Name ) (Las t Name ) (Jr./Sr ./III) (Child’s Age) (Street) (City) (State) (Zip) Request for Relief THEREFORE, I ask the court to change my name from the name stated in Paragraph 1 above to the name stated in Paragraph 2 above. Petition for Change of Name (For Adult Individual) Page 4 of 4 Form CAFC40 1 04/2016 This form is available for free at www .selfrepresent. mo.gov Sign Below in the Presence of a Notary Public Petitioner, of lawful age, being duly sworn on his or her oath, states that he or she is the petitioner named above and that the facts stated in this Petition for Change of Name (For Adult Individual) are true according to his or her best knowledge, information and belief. (Sign above in the presence of a Notary Public ) (Print your name above) The following information must be completed by a notary public. STATE OF ) ) SS COUNTY OF ) On this day of , 20 , before me personally appeared, , to me known to be the person desc ribed in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her f ree act and deed. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County and State aforesaid, the day and year first above written. , Notary Public County, State of Missouri My commis sion expires: Attorney Information This information may be completed by your attorney. Do not enter any information here if you are filing this case without the assistance of an attorney. I have assisted Petitioner in the preparation of these pleadings, but I am not entering my appearance on behalf of Petitioner. (Attorney - Sign above ) (Missouri Bar Number) (Attorney - Print your name above) (Street) (City) (State) (Zip) (Telephone Numbe r with Area Code) (Fax Number with Area Code ) (E-mail Address - Optional) Judgment for Change of Name of Adult Individual Page 1 of 2 Form CAFC47 0 04/2016 This form is available for free at www .selfrepresent. mo.gov IN THE CIRCUIT COURT OF , MISSOURI (Coun ty wher e cour t is loca ted. City of St. Louis is considered a county. ) In re: (First Name) (Middle Name) (Last Name) (Jr./Sr./III) Petitioner (Enter your full legal name above) Case No. ( Use number on Petition ) Division No. ( Use number on Petition ) Judgment for Change of Name of Adult Individual 1. Parties Appearing ( Check all that apply ) Petitioner (First Name) (Middle Name) (Last Name) (Jr./Sr./III) You are the Petitioner in this case. appears in person. appears by Attorney. 2. The court finds that the change of name would be proper and would not be detrimental to the interests of any other person. 3. The name of Petitioner is changed as follows: From (First Name) (Middle Name) (Last Name) (Jr./Sr./III) To (First Name) (Middle Name) (Last Name) (Jr./Sr./III) Birth Date (mm/dd/yyyy) 4. Change of Birth Records (Check one of the two boxes) It is further ordered that the Division of Health and Senior Services, Bureau of Vital St atistics for the State of Missouri alter the birth certificate of Petitioner to reflec t this judgment. This judgment shall be mailed by the Petitioner to the Division of Health and Senior Services . It is further ordered that the State of alter the birth certificate of Petitioner to reflect this judgment. This judgment shall be mai led by the Petitioner to the approp riate state of birth of Petitioner. Judgment for Change of Name of Adult Individual Page 2 of 2 Form CAFC47 0 04/2016 This form is available for free at www .selfrepresent. mo.gov 5. Notice (Check one of the two boxes) Notice of the change of name shall be published at least once each week for three consecutive weeks in the following newspaper of general circulation: No notice of change of name is to be published because the petitioner is the victim of a crime based upon domestic violence as defined in §455. 010, RSMo; or the victim of child abuse as defined in §210.110, RSMo; or the victim of abuse by a family or household member as defined in §455.010, RSMo. 6. Court Costs (Check one of the two boxes) Court costs are waived. Court costs are to be paid from the court cost deposit(s) previously posted. 7. Waiver of Right to Rehearing (If case is heard by a Commissione r pursuant to §487.010, RSMo , et seq.) We , the undersigned part ies, do hereby acknowledge receipt of the find ings and recommendations of the commissioner and waive the right to file a motion for rehearing in this case. Signature of Petitioner’s Attorney Signature of Petitioner (If heard by a Family Court Judge) (Judge) (Date) (If heard by a Family Court Commissioner) Findings and Recommendations of Commissioner: (Commissioner ) (Date) All orders and these findings and recommendations of the Commissioner are confirmed and adopted as the judgment of the court. (Judge) (Date) A certified copy of this judgment is to be mailed to the following person(s): (Check all applicable boxes) (Print Name of Petitioner’s Attorney) (Street) (City , State, Zip) (Telephone Number with Area Code) (Print Name of Petitioner) (Street) (City , State, Zip) (Telephon e Number with Area Code )