KSJC 12/2010 Page 2 of 3
5. Petitioner, __________________________________, is now and has been a resident
of Kansas, for a period of more than sixty (60) days immediately preceding the filing of the
6. Petitioner’s YEAR of birth is and petitioner’s place of birth is
____________________ County in the State of___________________________.
7. Petitioner’s birth certificate shows his/her name as ____________________________
8. Petitioner’s present name is: ____________________________________________.
9. Petitioner seeks to change his/her name to __________________________________
10. The Petition for Change of Name 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.
11. No objections have been made to the Court and the Court finds Petitioner is entitled
to have his/her name changed from ____________________________________ to:
IT IS THEREFORE BY THE COURT CONSIDERED, ORDERED, ADJUDGED,
AND DECREED that the above and foregoing findings are made as orders of this Court, that
Petitioner’s name be changed to _______________________________________________, and
that the costs of this proceeding are assessed against Petitioner.