Fill and Sign the Vermont Change Name 497429018 Form

Pc 122 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit       Unit Docket No. In re       of       PETITION OF ADULT TO CHANGE NAME The undersigned petitioner represents as follows: That I was born at       on       Town/city and state date of birth That I have the following minor children, who were born in the following locations: Name of child town/city and state date of birth                                                       That I am married to       of       That the name I wish to be known by is:       That I understand by fiinn this petition I consent to the court requestinn the Department of Pubiic Safety to determine whether the petitioner’s name appears on the sex ofender renistry estabiished by 13l V. S. A. §5402s and to disciosure of the information to the court by the department; and I understand that, if the department reports that the petitioner’s name appears on the renistry, the court shaii permit the department to appear on the question whether is a compeiiinn reason we been for nrantinn the petition. Date:       Signed: , Petitioner Print Name:       Mailing Address:             Telephone/email:       At       on this _____ day of ________________________, 20_____,       personally appeared before me and acknowledged this instrument by him/her signed, to be his/her free act and deed. 10/11 SML Judge/Register 10/11 SML