Fill and Sign the Vermont Change Name Form

STATE OF VERMONT PROBATE COURT DISTRICT OF ____________ In Re the Estate of: ) DOCKET No. __________ ) __________________ ) , Deceased ) ) ) LATE OF ) ) __________________ . ) ) ) PETITION TO CHANGE NAME OF MINOR Part I. Request for Change of Name The undersigned petitioner represents as follows: That the minor's name is: Name That the minor was born at City , ST on Date of Birth ; That the parents of the minor are: Name: __________________ Name: __________________ Address: __________________ Address __________________ ____________________________ ____________________________ ____________________________ ____________________________ That the guardian, if any, for the child was appointed by ____________________________ and has the following name and address: Court Name: ____________________________ Address ____________________________ - 1 - ____________________________ That my relationship to the child is: parent That the name I wish the minor to be known as is _______________________________________________________ That the reason for changing the minor's name is as follows: _______________________________________________________ Dated _________________________________________ _____________________________________________ Petitioner At ________________ on this __ day of____________, 20___, _________________________ personally appeared before me and acknowledged this instrument, by him subscribed, to be his free act and deed. ___________________________________________________________ Judge/Register Part II. Consent I, _________________________________ , whose relationship with the minor is that of _________________________________ , consent to the change of name of the minor from _________________________________ to the new name of _________________________________ . Dated at _____________ this ___ day of _________________ ,20 ___ . Note: 15 V.S.A. § 812 Signed ______________________________ states that "the name of a minor if over fourteen years of age, shall not be changed without consent given in court." Print Name _____________________________ Address ______________________________ - 2 - ______________________________ Telephone ______________________________ Rev. 3/1/89 - 3 -