CCR-A-160 Adult 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
COMES NOW the Petitioner, seeking a change of name pursuant to Virginia Code
§8.01-217, and respectfully states under oath as follows:
The Petitioner currently resides in the County [ ] City [ ] of Fairfax, Virginia.
The Petitioner 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 Petitioner is
_________________________ ________________________ ________________________
First Middle Last
The current address of the Petitioner (Street Address, City, State & Zip Code)
__________________________________________________________________________
Petitioner’s Date of Birth: ______________________
Petitioner’s Place of Birth: _____________________________________________________
Petitioner’s Parents’ Full Names:
___________________ __________________ __________________ _________________
First Middle Last Maiden (if applicable)
___________________ __________________ __________________ _________________
First Middle Last Maiden (if applicable)
Clear
CCR-A-160 Adult January 2020
Answer the following questions and provide information, if required:
1) Have you previously changed your name? [ ] Yes [ ] No
If yes, indicate all prior full names: __________________________________________
__________________________________________________________________________
2) Have you ever been convicted of a felony? [ ] Yes [ ] No
If yes, please provide charge(s)/dates:
__________________________________________
3) Are you currently incarcerated? [ ] Yes [ ] No
If yes, please indicate facility and location:
__________________________________________
4) Are you a probationer with any court(s)? [ ] Yes [ ] No
If yes, please indicate court(s) name:
__________________________________________
5) Are you 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 (Current Full Name)
__________________________________________
Printed Name of Petitioner (Current Full Name)
Email Address: _________________________________________________
Daytime Phone Number: __________________________________________
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 Adult 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
This day came the Petitioner, seeking a name change, pursuant to Virginia Code §8.01-217.
IT APPEARING to the Court that:
The current address of the Petitioner (Street Address, City, State & Zip Code) is:
__________________________________________________________________________
The Petitioner [ ] has not previously changed name.
[ ] has previously changed name from:
__________________________________________________________________________
ADJUDGED, ORDERED and DECREED that the name of the Petitioner 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
I ASK FOR THIS:
________________________________
Signature of Petitioner (Current Full Name)
Clear
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