Fill and Sign the Petition for Name Change Per Va Form

FORM CC-1411 (MASTER, PAGE TWO OF TWO) REVISED 12/05Va. Code § 8.01-217APPLICATION FOR CHANGE OF NAME (ADULT)Commonwealth of VirginiaVIRGINIA: In the Circuit Court of the City County of IN RE: COMES NOW, your Applicant, and after being duly sworn states under oath as follows:1.Applicant 's Birth Name: FIRST MIDDLELASTSUFFIX2.Residence Address: STREET ADDRESS CITY STATEZIP CODE COUNTRY3.Mailing Address: IF DIFFERENT FROM RESIDENCE ADDRESS4a. Date of Birth: 4b. Place of Birth: 5. Father's Full Name: FIRST MIDDLELASTSUFFIX6.Mother's Full Name: FIRST MIDDLEMAIDEN CURRENT LASTAnswer the following questions by checking appropriate ''Yes'' or ''No'' box and providing information as requested.7. Have you ever been convicted of a felony? Yes No 8. Are you currently incarcerated? ** Yes NoIf yes, indicate facility name: Facility Location: 9. Are you a probationer with any Court? ** Yes NoIf yes, indicate Court Name: 10. Have you previously changed your name? Yes No(If yes, attach Court Order or other documentation) FromTo Reason FORM CC-1411 (MASTER, PAGE TWO OF TWO) REVISED 12/05Va. Code § 8.01-217WHER EFO RE, y our applicant fu rth er c ertif ie s u nder o ath t h at t h is n am e c h an ge i s n ot s o ught f o r a n y f ra u dule n t p urp ose s an d w ill n ot i n frin ge u pon t h e r ig hts o f o th ers , a n d p urs u an t t o § 8 .0 1-2 17 o f t h e C ode o f V ir g in ia , 1 950, a s a m en ded , y our pe titio ner p ra y s t h at t h e C ourt o rd er a c h an ge o f n am e f ro m : FIRST MIDDLE LASTSUFFIX to FIRST MIDDLE LASTSUFFIX PETITIONER Commonwealth/State of City County of Subscribed and sworn to/affirmed before me on this date by the above-named person. DATE CLERK DEPUTY CLERK NOTARY PUBLIC My commission expires: ** Applications of probationers and incarcerated persons MAY be accepted if the Court finds good cause exists for such application Attach explanatory documentation to the application.