Fill and Sign the Petitioner Enter Your Full Legal Name above Form

Request for Publication after Judgment of Change of Name for Adult Individual Page 1 of 1 Form CAFC 480 10/28/2016 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 ) (Las t Name ) (Jr./Sr ./III) Cas e No. Pet itioner (Enter your full legal name above ) (Use number on Petition) Division No. (Use number on Petition) Request for Publication after Judgment of Change of Name for Adult Individual Missouri law requires the above notice to be published at least three times in a newspaper published i n the county where the person whose name is changed is residing, with the first publication within 20 days after the order of court is made. The proof of service must be filed with the court within 10 days aft er the date of last publication. Petitioner must pay for the cost of publication. Petitioner’s Name (before change) and address (First Name) (Middle Name) (Last Name) (Jr./Sr./III) (Street) (City) (State) (Zip) Notice to be Published in the Newspaper Publish the following change of name notice each week for three consecutive weeks : To Whom It May Concern: Notice is hereby given that by an order of the Circuit Court of the County of , Missouri, Division No. , Case No. made entered on the record on , the name of (enter name before change) mm/dd/yyyy (First Name) (Middle Name) (Last Name) (Jr./Sr./III) was changed to (enter name after change) . (First Name) (Middle Name) (Last Name) (Jr./Sr./III) Enter the newspaper(s) in which your notice shall appear. The newspaper shall send proof of publication to the circuit court of the county of , Missouri. Signature of Petitioner (name before change):