Fill and Sign the Virginia Name Change Order Form

APPLICATION FOR CHANGE OF NAME (ADULT) Commonwealth of Virginia VIRGINIA: In the Circuit Court of the City County of       IN RE:       COMES NOW, your Applicant,       and after being duly sworn states under oath as follows: 1. Applicant 's Birth Name:                         FIRST MIDDLE LAST SUFFIX 2. Residence Address:       STREET ADDRESS                         CITY STATE ZIP CODE COUNTRY 3. Mailing Address:       IF DIFFERENT FROM RESIDENCE ADDRESS 4 a. Date of Birth:       4b. Place of Birth:       5. Father's Full Name:                         FIRST MIDDLE LAST SUFFIX 6. Mother's Full Name:                         FIRST MIDDLE MAIDEN CURRENT LAST Answer the following questions by checking appropriate ''Yes'' or ''No'' box and providing information as requested. 7. Have you ever been convicted of a felony? Yes No 8. Are you currently incarcerated? ** Yes No If yes, indicate facility name:       Facility Location:       9. Are you a probationer with any Court? ** Yes No If yes, indicate Court Name:       10. Have you previously changed your name? Yes No (If yes, attach Court Order or other documentation) From To Reason                                                       FORM CC-1411 (MASTER, PAGE TWO OF TWO) REVISED 12/05 Va. Code § 8.01-217 WHEREFORE, your applicant further certifies under oath that this name change is not sought for any fraudulent purposes and will not infringe upon the rights of others, and pursuant to § 8.01-217 of the Code of Virginia, 1950, as amended, your petitioner prays that the Court order a change of name from :       FIRST MIDDLE LAST SUFFIX to       FIRST MIDDLE LAST SUFFIX PETITIONER Commonwealth/State of       City County of       Subscribed and sworn to/affirmed before me on this date by the above-named person.       DATE CLERK DEPUTY CLERK NOTARY PUBLIC My commission expires:       ** Applications of probationers and incarcerated persons MAY be accepted if the Court finds good cause exists for such application Attach explanatory documentation to the application. FORM CC-1411 (MASTER, PAGE TWO OF TWO) REVISED 12/05 Va. Code § 8.01-217 FORM CC-1411 (MASTER, PAGE TWO OF TWO) REVISED 12/05 Va. Code § 8.01-217