Fill and Sign the Washington Petition for Change of Name 481374769 Form

________________________________________________________________________\ ______ Petition for Change of Name (rev 5/17) PAGE 1 OF 2 IN THE DISTRICT COURT OF T HE STATE OF W ASHINGTON IN AND FOR THE COUNTY OF ________ In the Matter of the Petition of _________________________________________________ Petitioner (Current Full Legal Name) Date of Birth ______________ Age ________ NO. ___________________ PETITION FOR CHANGE OF NAME (RCW 4.24.130) 1. I am applying for a Court Order which will change my name : A. FROM: (Current Full Legal Name) Current First Name Current Mi ddle Name Current Last Name B. TO: (New Legal Name De sired) Proposed First Name Proposed Middle Name Proposed Last Name 2. This “Petition for Change of Name” is made for the following reason(s): __ _______________________ ____ ___________________________ ____ __________________ __ _______________________ ____ ___________________________ ____ __________________ __ _______________________ ____ ___________________________ ____ __________________ __ _______________________ ____ ___________________________ ____ __________________ __ _______________________ ____ ___________________________ ____ __________________ __ _______________________ ____ ___________________________ ____ __________________ 3. I reside in County? ____________________________________________ 4. My physical (residential) a ddress: __ ____ ____ ____ ____ ____ ____ ____ __________________ ________________________________________________ Phone Number: _______________________________________________ ________________________________________________________________________\ ______ Petition for Change of Name (rev 5/17) PAGE 2 OF 2 5. Does any person (entity) have guardianship over your person or estate?\ ☐ Yes ☐ No 6. Do you have picture identification to show and be copied by the Clerk? ☐ Yes ☐ No 7. Is this Petition being made to avoid creditors? ☐ Yes ☐ No 8. Is this Petition being made for any illegal or fraudulent purpose? ☐ Yes ☐ No 9. Is this Petition being made because of domestic violence and you desire to have the name changed sealed due to reasonable fear for safety (RCW 4.24.130 (5))? ☐ Yes ☐ No If you marked “Yes” – You must file your Sealed Name Change Petition with Superior Court. 10. I AM under the jurisdiction of the Department of Corrections (or under probation with the Department of Corrections)? * ☐ Yes ☐ No 11. I AM required to register as sex offender under RCW 9A.44.130?** ☐ Yes ☐ No 12. Is there anything else you would like to present to the Court in support of your name change? Please describe. _______________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ *** I certify (or declare) under penalty of perjury under the la ws of the State o f Washington that the foreg oing statements in this petition are true a nd correct. Signed at ________ __ _ County, Washingto n on this the _____ day of __ ___________, 2017. ____________________________________________ Petitioner’s Signature ____________________________________________ Print Petitioner’s Name * If under the jurisdiction of Department of Corrections, a copy of this application (p etition) shall be submitted (BY THE PETITIONER) to said Department not fewer than five (5) da ys before entry of an o rder granting name change (AND HAVE PROOF OF SAME), and offender shall submit a copy of the order to said Department within five (5 ) days of entry of an order granting name change. Violation of a misdemeanor. RCW 4. 24. 130(2). ** If subject to registration under RCW 9A.44.130 (sex o ffender statute) a copy of this application (petitio n) shall be submitted (BY THE PETITIONER) to the County Sheriff AND the Washin gton State Patrol not fewer than five (5) days b efore entry of an order granting name change (AND HAVE PROOF OF SAME), and offender shall su bmit a copy of the order to said Sheriff and the WSP within three (3) business days of entry o f an order grantin g name change. See RCW 9.44.130(7). District Court complies with Americans with Disability Act – for accommodations contact Court Operations Manager 477-2903