Fill and Sign the Petition for Change of Name Relating to Family Division Form

NHJB-2319-F (07/01/2011) Page 1 of 3 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Name change of P ETITION FOR CHANGE OF NAME related to FAMILY DIVISI ON JURISDICTION for ADULT MINOR (pursuant to RSA 490-D:2, X) 1. The petitioner is filing this name change request with the Family Division because the request relates to the following type of case (check all that apply): Divorce Parenting Petition Petition for Paternity Annulment Petition for Support Domestic Violence Petition Guardianship Abuse and Neglect Delinquency/CHINS Adoption Termination of Parental Rights List Court Name(s) , Case Name(s) and Case Number(s) of the related case(s). Note: If the name change request DOES NOT relate to one of the case types above, the petitioner should file for a name ch ange with the Probate Division. 2. The petitioner requests that the name (First, middle and last names) be changed to in accordance with (First, middle and last names) the laws of the State of New Hampshire and for the following reasons: 3. Petitioner Name Telephone Mailing Address 4. Minor Name (if applicable) Telephone Mailing Address Relationship of petitioner to minor Case Name: Name change of Case Number: PETITION FOR CHANGE OF NAME NHJB-2319-F (07/01/2011) Page 2 of 3 5. Attorney Name (if applicable) Telephone Mailing Address PLEASE COMPLETE THE FOLLOWING INFORM ATION AS IT APPLIES TO THE PERSON WHOSE NAME IS BEING CHANGED. 6. Town of residence 7. Date of birth Place of birth 8. If minor, name of mother Mailing Address 9. If minor, name of father Mailing Address 10. If minor, name of guardian(s), if any Mailing Address 11. Check the following paragraphs that apply to the person whose name is being changed. I am a person who is serving a prison sentenc e, or who is on probation or parole, and I certify that I have sent a copy of this petition to the department of corrections as required by law. I understand that failure to comply wit h notification requirements shall cause any decree hereunder to be null and void. I am a person who is required to register as a sexual offender or an offender against children pursuant to RSA 651-B, and I certify that I have sent a copy of this petition to the department of safety or other agency as required by law. I unders tand that failure to comply with notification requirement s shall cause any decree hereunder to be null and void. Neither of the above paragraphs is applicable to this name change. 12. I authorize the court to conduc t a criminal record check on my current name and any previous names I have used, or to conduct a criminal record check on any names us\ ed by the person whose name I am seeking to change, by submitting the attached Criminal Record Rel\ ease Authorization Form. Date Petitioner Signature State of , County of This instrument was ack nowledged before me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title Case Name: Name change of Case Number: PETITION FOR CHANGE OF NAME NHJB-2319-F (07/01/2011) Page 3 of 3 ORDER The above petitioner has sworn before the judge/master that the facts are tr ue to his/her best knowledge and belief. Accordingl y, the court orders that: Petition is granted. Petition is denied. Recommended: Date Signature of Marital Master Printed Name of Marital Master So Ordered: I hereby certify that I have r ead the recommendation(s) and agree tha t, to the extent the marital master/judicial referee/hearing officer has made factual findings, she/he has applied the correct legal standard to the facts determined by the marita l master/judicial referee/hearing officer. Date Signature of Judge Printed Name of Judge