Fill and Sign the State of South Dakota in Circuit Court Ss 490219195 Form

Form UJS -027 Order for Adult Name Change Rev. 06/2011 STATE OF SOUTH DAKOTA ) IN CIRCUIT COURT )ss: COUNTY OF ______ _______ _________ ) ___________ JUDICIAL CIRCUIT ) ******************************************************************************* In the Matter of the Petition of ) ) _________________________________ ) CIV: _______________ (Current Name) ) ) For a Change of Name to ) ORDER FOR ADULT NAME CHANGE ) ___________________________________ ) (Proposed Name) ) ) ********************* ********************************************************** The above -entitled matter having come before th is Court , on this __ _____ _ day of ____ ______ ____ _____, 20___; the P etitioner __________ ________ ________________________, appearing personally and no one appearing in opposition to said Verified Petition for Adult Name Change ; now, upon the testimony, evidence and entire record, it is , by the Court FOUND AND DETERMINED that the Court has full and complete jurisdiction of the subject matter hereof pursua nt to SDCL chapter 21 -37, SDCL 34 -25 -51, and ARSD 44:09:05:02 ; and it is further FOUND AND DETERMINED that at the time of filing the Verified Petition for Adult Name Change herein, the Petitioner is a resident of __ __________ _________________ County, South Dakota and has been a bona fide resident of __________ _____ ___ __ _______ County, South Dakota for more than six months prior to the filing of the petition ; and it is further FOUND AND DETERMINED that notice of the proposed name change was given by publica tion of the same once each week for four successi ve weeks as required by SDCL § 21 -37 -4 as shown by the Affidavit of Publication of __________ _____ _______ ___ _______ (name of legal county newspaper) on file herein; and it is further Form UJS -027 Order for Adult Name Change Rev. 06/2011 FOUND AND DETERMINED that: 1. Petitioner’s full name on p etitioner’s birth certificate is ___ ___ _____ ____ __________ ______________________________________________________________________ ; 2. Petitioner’s date of birth is _____________________________ ____ _______________; 3. Petitioner wa s born in the State of _________ __________________ ______, County of _______________________________, and city or town of __ ____________________; 4. Petitioner’s mother’s full maiden name as it appears on petitioner’ s birth certificate is _____________________ _____________________________ __ __________________; 5. Petitioner’s fathe r’s full name as it appears on p etitioner’s b irth certificate is ____ _____ _____________________________________________________________________ _; and it is further FOUND AND DETERMINED that the name of th e p etitioner, as it appears on petitioner’s birth certificate, ________________________________________________________ __________ , shall be changed to _________________ __ ____________________________________________; and it is further FO UND AND DETERMINED that th e allegations set forth in the Verified P etition for Adult Name Change are true and there is reasonable and proper caus e for changing the name of the petitioner; NOW, THEREFORE, IT IS ORDERED, ADJUDGED AND DECREED, that the name of the petitioner, as it appears on p etitioner’s birth certificate, __________________________________ ______ ______ ________ shall be changed to ________________________________________________________________ and this Order shall be entered by the clerk; a nd it is further Form UJS -027 Order for Adult Name Change Rev. 06/2011 ORDERED, ADJUDGED AND DECREED, that should petitioner choose to change petitioner’s birth certificate, the petitioner must provide the Department of Health Office of Vital Records in the state where the petitioner was born with a certifie d copy this “Order for Adult Name Change ” and pay Department of Health Office of Vital Records the applicable filing fee for amending the birth certificate ; that the Department of Health, Office of Vital Records in the state where the p etitioner was born shall loca te the petitioner’s birth certificate using the identifying information above , verify that information within the state’s vital records registration system , and , within a reasonable time after receiving both the certified copy of this “Order for Adult N ame Change ” and the applicable fee from p etitioner, ame nd the petitioner’s birth certificate by changing the petitioner’s name of __________________ ___ ___ ___________________________ _, currently on the birth certificate , to the name of _____________________ ___ ________________________. Dated this ____ day of ___ __________ _____________, 20_ ____ __. By The Court ____________________ _______ __________ Circuit Court Judge ATTEST: ______________ __ _______________ Clerk of Courts By: ________ __ __ ________________ Deputy