KSJC 12/2010 Page 1 of 2
IN THE EIGHTEENTH JUDICIAL DISTRICT
DISTRICT COURT OF SEDGWICK COUNTY, KANSAS
Case No. _____________
Div. No. _____________
PETITION FOR CHANGE OF NAME
Pursuant to K.S.A. 60-1402
Petitioner states:
1. I reside in the County in which this Petition is being filed.
2. I have been a resident of Kansas for more than sixty (60) days before filing this
petition.
3. My YEAR of birth is and my place of birth is ______________ County
in the State of ______________________.
4. My birth certificate shows my name as:_____________________________________.
5. My present name is: ______________________________________________.
6. Other names I am using or have used are: ___________________________________
_____________________________________________________________________________.
7. I desire to have my name changed to:_______________________________________
because_______________________________________________________________________
___________________________________________________________________________.
IN THE MATTER OF THE PETITION OF
Present Name
To Change His/Her Name to:
New Name
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
Name (Print):______________________________
Address 1: ________________________________
Address 2: ________________________________
City, State, Zip: ____________________________
Telephone Number: _________________________
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