CCR-A-160 Minor January 2020
V I R G I N I A
FAIRFAX CIRCUIT COURT
IN THE MATTER OF THE CHANGE OF NAME OF: CL No._______ - ______________
_________________________ ________________________ ________________________
First Middle Last
to ________________________ ________________________ _______________________
First Middle Last
PETITION FOR CHANGE OF NAME OF MINOR CHILD/WARD
COMES NOW the Petitioner(s) seeking a change of name for the Child/Ward pursuant
to Virginia Code §8.01-217 and respectfully states under oath as follows:
The Child/Ward currently resides in the County [ ] City [ ] of Fairfax, Virginia.
The Child/Ward desires a change of name for the following reasons:
__________________________________________________________________________
This change of name is not sought for any fraudulent purpose and will not infringe on the
rights of another.
The current legal name of the Child/Ward is
__________________________________________________________________________
The current address of the Child/Ward (Street Address, City, State & Zip Code)
__________________________________________________________________________
Child’s/Ward’s Date of Birth: ___________________
Child’s/Ward’s Place of Birth: __________________________________________________
Child’s/Ward’s Parents’ Full Names:
___________________ __________________ __________________ _________________
First Middle Last Maiden (if applicable)
___________________ __________________ __________________ _________________
First Middle Last Maiden (if applicable)
Answer the following questions and provide information if required;
1) Has the Child/Ward previously had a name change? [ ] Yes [ ] No
If yes, indicate all prior full names: __________________________________________
__________________________________________________________________________
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CCR-A-160 Minor January 2020
2) Has the Child/Ward ever been convicted of a felony? [ ] Yes [ ] No
If yes, please provide charge(s)/dates:
__________________________________________
3) Is the Child/Ward currently incarcerated? [ ] Yes [ ] No
If yes, please indicate facility and location:
__________________________________________
4) Is the Child/Ward a probationer with any court(s)? [ ] Yes [ ] No
If yes, please indicate court(s) name:
__________________________________________
5) Is the Child/Ward required to register with the Sex
Offender and Crimes Against Minors Registry? [ ] Yes [ ] No
If yes, please indicate court(s) of conviction:
__________________________________________
____________________________________ ___________________________________
Signature of Petitioner #1 Signature of Petitioner #2
____________________________________ ___________________________________
Printed Name of Petitioner #1 Printed Name of Petitioner #2
Email Address:________________________ Email Address:_______________________
Daytime Phone #:______________________ Daytime Phone #:_____________________
*****If there are TWO petitioners, EACH Petitioner's Signature must be notarized*****
IN THE COMMONWEALTH OF VIRGINIA, COUNTY
OF
__________________________________________:
I, the undersigned Deputy Clerk/Notary Public in and
for the Commonwealth of Virginia, do hereby certify
that before me appeared
__________________________________________,
whose name is signed to the foregoing Petition, and
acknowledged the same under oath before me.
Given under my hand and seal this
_______ day of _____________________, _______.
__________________________________________
Deputy Clerk/ Notary Public
My Commission Expires: ______________________
Notary Registration #: ________________________
IN THE COMMONWEALTH OF VIRGINIA, COUNTY
OF
__________________________________________:
I, the undersigned Deputy Clerk/Notary Public in and
for the Commonwealth of Virginia, do hereby certify
that before me appeared
__________________________________________,
whose name is signed to the foregoing Petition, and
acknowledged the same under oath before me.
Given under my hand and seal this
_______ day of _____________________, _______.
__________________________________________
Deputy Clerk/ Notary Public
My Commission Expires: ______________________
Notary Registration #: ________________________
CCR-A-160 Minor January 2020
V I R G I N I A
FAIRFAX CIRCUIT COURT
IN THE MATTER OF THE CHANGE OF NAME OF: CL No.________ - _____________
_________________________ ________________________ ________________________
First Middle Last
to ________________________ ________________________ _______________________
First Middle Last
FINAL ORDER OF NAME CHANGE OF MINOR CHILD/WARD
This day came the Petitioner(s), seeking to change the name of the Child/Ward, pursuant to
Virginia Code §8.01-217.
IT APPEARING to the Court that:
The current address of the Child/Ward is: (Street Address, City, State, and Zip Code) is:
_________________________________________________________________________.
The Child/Ward [ ] has not previously had a change of name.
[ ] has previously had a changed name from:
_________________________________________________________________________.
ADJUDGED, ORDERED and DECREED that the name of the Child/Ward is hereby
changed from
_________________________ ________________________ ________________________
First Middle Last
to ________________________ ________________________ _______________________
First Middle Last
and it is further ADJUDGED, ORDERED, and DECREED that the Clerk of this Court,
pursuant to the provisions of Virginia Code §8.01-217, shall spread this Order upon the
current deed book, index it in both the old and new names, and transmit a certified copy to
both the State Registrar of Vital Statistics and the Criminal Records Exchange.
Entered this ____________ day of ______________________________, __________.
___________________ _________
JUDGE
WE ASK FOR THIS:
____________________________________ ___________________________________
Signature of Petitioner #1 Signature of Petitioner #2
Clear
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