KSJC 12/2010 Page 2 of 2
8. This Petition is not made for the purpose of avoiding any debts, obligations or legal
process nor is it made for the purpose of misleading or defrauding any person. The requested
name change will not result in prejudice to any person.
9. My best interests are served by the requested change in name.
I ask the Court to set this matter for hearing and order service by publication, registered
mail or certified mail, or, if appropriate, waive any requirement for service. I further ask the
Court to issue an order changing my name from ______________________________________
to ____________________________________ and for such other relief as the Court deems
appropriate under the circumstances.
I affirm under penalty of perjury that all statements in this Petition for Change of Name
are accurate to best of my knowledge.
Petitioner, Pro Se
Address 1: ________________________________
Address 2: ________________________________
City, State, Zip: ____________________________
Telephone Number: _________________________