Fill and Sign the Verified Name Change Form

STATE OF INDIANA ) IN THE CIRCUIT COURT ) SS: COUNTY OF _______________ ) CASE NO. __________________ IN RE THE NAME CHANGE OF: ) ) ) _________________ ) Petitioner. ) VERIFIED PETITION FOR CHANGE OF NAME Petitioner,       , pro se, respectfully petitions this court to change his/her/ name. In support of this Petition, Petitioner states as follows: 1. That my current name is:       . 2. That my date of birth is:       . 3. That my Indiana driver’s license number/Indiana identification card number is       ; and I will bring my Indiana driver’s license or identification card to my Change of Name Hearing for verification. 4. That my mailing address is:             And, if different, my residence address is:             . 5. The following is a list of all my previous names:       . 6. That I do hold a valid United States passport. My proof that I am a United States citizen is       . I will bring this document to my Change of Name Hearing for verification. 7. That the following judgments of criminal conviction of a felony under the laws of any state or the United States have been entered against me, or I have stated immediately below that I have no felony convictions:       . Page 1 of 2 Form PS-34282-1 Revised by State Court Administration 10/10 8. That I am not seeking to defraud creditors by changing my name. 9. That I have published notice of my request for name change in a local publication as required by law, and will bring proof of publication to the hearing. 10. That I am not a sex or violent offender who is required to register under I.C. 11-8-8. 11. That pursuant to Indiana Code 34-28-2-1, I was to change my name. The reason I want to change my name is:       . 12. That I wish to change my name to       . WHEREFORE, I respectfully request that this Court grant my Petition for Name Change, and for all other just and proper relief. I affirm, under the penalties of perjury that the foregoing representations are true. Signature                   Page 2 of 2 Form PS-34282-1 Revised by State Court Administration 10/10