Fill and Sign the This Day Came the Applicant Having Filed Hisher Verified Application Requesting the Change of Hisher Name from Form

ORDER FOR CHANGE OF NAME(ADULT)Case No. ....................................................... Commonwealth of Virginia VA. CODE §§ 8.01-217, 20-121.4 VIRGINIA: In the Cir cuit Court of the[ ] City [ ] County of ......................................................................................... In re : This day came the applicant having filed his/her verified application requesting the change of his/her name from .................................................................................................................................................................................... FIRST MIDDLE LAST SUFFIX to .................................................................................................................................................................................... FIRST MIDDLE LAST SUFFIX Additional former name(s) of the applicant: ...................................................................................................................... The applicant’s address is: ............................................................................................................................................. [ ] The Court finds that [ ] the application complies with the requirements of subsection B of Virginia Code § 8.01-217, [ ] a motion was made pursuant to Va. Code § 20-121.4 incident to divorce, the change of name is not sought for any fraudulent purpose, and the change of name would not otherwise infringe upon the rights of others. [ ] The Court previously found that the applicant is presently incarcerated, a probationer, or a person for whom registration with the Sex Offender and Crim es Against Minors Registry is required but found good cause for consideration of the application and conducted a hearing on the application. [ ] The Court finds that the change of name would not frust rate a legitimate law enforcement purpose, is not sought for a fraudulent purpose, and would not otherwise infringe upon the rights of others. The basis for this finding is as follows: ..................................................................................................................................................... .................................................................................................................................................................. .................................................................................................................................................................. Accordingly, it is ADJ UDGED and ORDERED that [ ] The applicant’s name is hereby changed, effective this date, to .................................................................................................................................................................................... and this cause is ended. [ ] The Clerk of this Court shall forthwith sp read this Order upon the current deed book, indexing the order in both the old and new names. [ ] The Clerk of this Court shall further tran smit a certified copy of this Order and the application to the State Registrar of Vital Records and to the Central Cr iminal Records Exchange. [ ] This change of name is granted incident to a divorce and the Clerk shall not transmit any copy of this Order to the Registrar of Vital Records or to the Ce ntral Criminal Records Exchange. [ ] Public recording of the name change would pose a serious threat to the health or safety of the applicant/applicant’s family and the record of this cause is hereby Ordered sealed. The Cl erk shall not spread or index this Order and shall not transmit any copy of this Order to the Re gistrar of Vital Records or to the Central Criminal Records Exchange. [ ] The application for change of name is he reby denied and this cause is dismissed. Entered this ........................ day of ...................................................................... , 20 ............................. . _____________________________________________________________________ JUDGE FORM CC-1412 MASTER 07/14