Fill and Sign the County Name Form

This form is approved by the Illinois Supreme Court and is required to be accepted in all Illinois courts. NC-R 303.5 Page 1 of 2 (03/1 8) STATE OF ILLINOIS , REQUEST FOR NAME CHANGE (ADULT) For Court Use Only CIRCUIT COURT COUNTY Instructions  Directly above , enter the county name where you will file this case. Request of: Enter your current name. DO NOT enter a Case Number , the Circuit C lerk will add it. Your current name (First, middle, last name ) Case Number In 1, enter your complete current name. I ask the court to enter an order to change my name, and I state: 1. My current name is: In 2, enter the new full name you would like. First Middle Last In 3, enter your complete current address. 2. I wish my name to be changed to: First Middle Last In 4, enter the date you started living in Illinois. 3. My address is: Street City State ZIP 4. I have lived continuously in Illinois for at least 6 months beginning : In 5, enter your date of birth Date 5. My birth date is: In 6, enter the city, county, state, and country where you were born. Date 6. My place of birth i s: City County State/Province Country In 7-9 , check the boxes that apply to your criminal history. 7. I  have  have not been adjudicated or convicted of a felony or misdemeanor in Illinois or any other state for which a pardon has not been granted. In 10, 11 , and 12 check whether you have or have not been convicted or put on probation for the crime listed. 8. I  do  do not have an arrest for which charges have not been filed. 9. I  do  do not have a pending felony or misdemeanor charge. If you checked “have” in 10 or 11 and have not been pardoned, the court cannot give you a name change . 10. I  have  have not been convicted of or placed on probation for a crime which require s me to register as a sex offender in Illinois or any other state. 11. I  have  have not been convicted of or placed on probation for identity If you check ed “have ” in 12 and have not been pardoned or have not completed your probation or sentence over 10 years ago, the court may not give you a name change . theft or aggravated identity theft in Illinois or any other state. 12. I  have  have not been convicted of or placed on probation for a felony in Illinois or any other state. Enter the Case Number given by the Circuit Clerk: _________________________________ NC-R 303.5 Page 2 of 2 (03/1 8) In 13, describe what you were convicted of or placed on probation for, if you checked “have” in 10, 11, or 12. If you run out of space, use a separate piece of paper. 13. If you checked "have" in 10, 11, or 12 complete the following: Description of Felony or Misdemeanor Date of Conviction or Probation Sentence Received (include parole and supervised release) Date Sentence Completed Pardoned? (Yes or No) Under the Code of Civil Procedure, 735 ILCS 5/1-109 , making a statement on this form that you know to be false is perjury, a Class 3 Felony. I certify that everything above is true and correct. I understand that making a false statement on this form is perjury and has penalties provided by law under 735 ILCS 5/1 -109 . /s/ Your Signature Street Address If you are completing this form on a computer, sign your name by typing it. If you are completing it by hand, sign and print your name. Print Your Name City, State, ZIP Telephone GETTING COURT DOCUMENTS BY EMAIL: If you agree to receive court documents by email, check the box below and enter your em ail address. You should use an email account that you do not share with anyone else and that you c heck every day. If you do not check your email every day, you may miss important information or notice of court dates. Other parties may still s end you court documents by mail.  I agree to receive court documents at this email address during my entire case. Email NOTE This section should be filled out by someone else, not the person asking for a name change. VERIFICATION BY WITNESS I, First Middle Last Witness: Enter your full name. certify that what is stated above is true and correct to the best of my knowledge and belief. Under the Code of Civil Procedure, 735 ILCS 5/1-109 , making a statement on this form that you know to be false is perjury, a Class 3 Felony. Witness Signature Witness Name Witness: Sign and print your name. Street Address Witness: Enter your complete address. City, State, ZIP