Fill and Sign the Request for Summary Disposition of Petition for Change of Name Form

© 2017 Nevada Supreme Court Page 1 of 2 - Request for Summary Disposition – Adult Name Change Your Name: ________________________ Address: ___________________________ City, State, Zip: _____________________ Phone: ____________________________ Email: ____________________________ Self-Represented Petitioner DISTRICT COURT _________________ COUNTY, NEVADA In the Matter of the Application of: ___________________________________ ( print the old name you do not want anymore ) For Change of Name. CASE NO.: ____________________ DEPT: _____________________ REQUEST FOR SUMMARY DISPOSITION OF PETITION FOR CHANGE OF NAME AND DECLARATION IN SUPPORT Petitioner requests a summary disposition fo r a change of name without a hearing. Submitted By: ( your signature )  _______________________________ (print your name ) _______________________________ Page 2 of 2 – Request for Summary Disposition – Adult Name Change DECLARATION OF PETITIONER Petitioner respectfully states as follows: 1. I am the Petitioner in this case. I first moved to ____________ County, Nevada on ( date ) ______________. I intend to live in ____ ________ County, Nevada indefinitely. 2. I live at ( street address ) ___________________________________________________, ( city ) ________________________, Nevada, ( zip code) ______________. 3. I have read the Petition for Change of Name in this case and can testify that the allegations are true and correct to the best of my knowledge. 4. I request that the Court change my legal name from (clearly print your old name you do not want anymore ) _____________________ ______________________ _______________________ ( first) ( middle) ( last) to ( clearly print the name you want to be known by in the future) _____________________ ______________________ _______________________ ( first) ( middle) ( last) 5. I ( ☒ check one )  have /  have not been convicted of a felony. Any felony convictions are described in the Petition fo r Change of Name, and I have submitted my complete set of fingerprints as required. 6. I am not changing my name in order to defr aud creditors or for some other fraudulent reason. I declare under penalty of perjury under the la w of the State of Nevada that the foregoing is true and correct. DATED this ( day) ______ day of ( month) ___________________, 20____. Submitted By: ( your signature )  _______________________________ (print your name ) _______________________________