Form C- Rev 02/2018 Page 1
Form C- Name Change of Minor by Both Parents
INSTRUCTIONS FOR CHANGE OF NAME
Please read the Instructions for Change of Name carefully or have someone explain them to you. All forms
must be typed.
THE FOLLOWING FORMS ARE INCLUDED IN THIS PACKET AND MUST BE SUBMITTED
UPON COMPLETION:
PETITION
FACT SHEET
NOTICE OF CHANGE OF NAME
ORDER
$50 NON-REFUNDABLE FILING FEE
A filing fee in the amount of $50.00 is required for each name change Petition. Once
received by the Office of the Lieutenant Governor, this fee is non-refundable. All
Petitions must be accompanied by a Money Order or Cashier’s Check made payable to
the Office of the Lieutenant Governor in the amount of $50.00. No personal checks will
be accepted. Cash payment will only be accepted when the Petitioner hand carries
documents into the Office of the Lieutenant Governor.
Form C- Rev 02/2018 Page 2
INSTRUCTIONS FOR COMPLETING THE PETITION (pages 6 to 8)
(1)
This is the official heading. You type in the full, legal name of each parent, one on each line.
Type the child’s full name exactly as it appears on the birth certificate (unless it has been legally
changed) in the space after “for and on behalf of.” DO NOT TYPE IN THE NAME YOU
ARE USING NOW UNLESS IT IS YOUR LEGAL NAME.
(2)
Type your full name of each parent just as they appear in the heading.
(3)
Type in all the information requested for each parent. Type each Petitioner’s father’s full name
and mother’s first name and maiden name.
(4)
Type in the child’s date of birth, the child’s place of birth, and the name of the child as it
appears in the heading.
(5)
Type the child’s name exactly as you want it to appear after it is changed.
(6)
Type in Petitioner’s state of residence and current address. If Petitioners live at different
addresses, type both addresses and identify as “mother’s” and “father’s.
(7)
Type the child’s name as it appears in the heading and then the name as you want it to be after it
is changed.
(8)
Type the date in the first blank. Type the date, either at the time you have it notarized or before
you have it notarized. If you date it after the date it is notarized, it will not be processed. Type
the name of the city on the second blank.
(9)
Sign the petition in black ink, exactly as it is typed in the heading. DO NOT USE INITIALS OR
NICKNAMES IN THE SIGNATURE.
(10)
Type in both parent names in the spaces provided.
(11)
Sign petition in black ink in front of a State of Hawaii notary public. DO NOT USE INITIALS
OR NICKNAMES IN THE SIGNATURE. The notary will complete their portion of this page.
Notary Public must be commissioned in the State of Hawaii.
Form C- Rev 02/2018 Page 3
INSTRUCTIONS FOR COMPLETING THE NOTICE OF CHANGE OF NAME (page 11)
At the top of the page, type Petitioners’ names, address and telephone number in the space provided.
Type in the full, legal name of each parent, one on each line after In the Matter of the Petition of”.
Type the child’s full name exactly as it appears on the birth certificate (unless it has been legally
changed) in the space after “for and on behalf of”.
Type the full name of each parent just as they appear on the Birth Certificate and as you want it to
appear after it is changed.
Submit one (1) original of NOTICE OF CHANGE OF NAME. Copies are not required. Once your
Petition has been approved, the Lieutenant Governor will sign the NOTICE OF CHANGE OF NAME and
it will be returned to you. You will be responsible for submitting the NOTICE OF CHANGE OF
NAME to the newspaper agency for publication. The NOTICE OF CHANGE OF NAME must be
published in the newspaper and affidavit executed within sixty (60) calendar days after it is signed by the
Lieutenant Governor.
Failure to publish within the time required automatically voids the Petition for Change of Name.
The newspaper will mail an AFFIDAVIT of publication to our office and a copy of the AFFIDAVIT to
you, for your files. If we do not receive an AFFIDAVIT from the newspaper by the end of the sixty (60)
days, we will assume that you did not have the NOTICE OF CHANGE OF NAME published and your
Petition will be voided at the end of sixty (60) days.
NOTE: The newspaper provides the affidavit, you do not have to provide that form.
Form C- Rev 02/2018 Page 4
INSTRUCTIONS FOR COMPLETING THE ORDER (pages 12 to 13)
Halfway down the page, type in petitioners’ names, addresses and telephone numbers in the
space provided.
Type in the full, legal name of each parent, one on each line after In the Matter of the Petition of.”
Type the child’s full name exactly as it appears on the birth certificate (unless it has been legally
changed) in the space after “for and on behalf of”.
Type the child’s name exactly as it appears in the heading, and then the name you want it to be after
it is changed.
Leave all other spaces blank.
Submit one (1) original and five (5) copies of the ORDER to our office along with the original Petition.
Once our office receives the AFFIDAVIT from the newspaper showing publication of your name
change, the Lieutenant Governor will sign the administrative ORDER and it will be sent to you. You
must file the original ORDER with the Bureau of Conveyances within sixty (60) days after the signing
of the ORDER. (See H.R.S. 574-6b).
INSTRUCTIONS FOR RETURNING DOCUMENTS
Mail or deliver the documents to:
Office of the Lieutenant Governor
Hawaii State Capitol
415 South Beretania Street, 5th Floor
Honolulu, Hawaii 96813
Please do not hesitate to contact our office prior to submitting documents and payment if you have any
questions, as the filing fee is non-refundable.
Phone: (808) 586-0255
Website: www.ltgov.hawaii.gov
Form C- Rev 02/2018 Page 5
The following must be submitted to the Lieutenant Governor’s Office.
BIRTH CERTIFICATE OR CERTIFICATE OF NATURALIZATION- a certified copy of
your original birth certificate from the state in which you were born. Certification of the
birth certificate must not be older than 90 days prior to submission of your name change
Petition. Original Certificate of Naturalization (if applicable) must also be submitted.
If you are not a U.S. Citizen, please provide a photocopy of your passport AND either of the
following: (1) foreign birth certificate, which must be translated into English and notarized;
(2) family register; or (3) alien registration card. Parents will submit a photocopy of their
birth certificates.
PETITION- notarized by a State of Hawaii notary public within 30 days prior to submission
of name change forms.
FACT SHEET- completed fact sheet.
NOTICE OF CHANGE OF NAME- one original
ORDER- original plus five (5) copies
NON-REFUNDABLE FILING FEE- Money Order or Cashier’s Check made payable to the
Office of the Lieutenant Governor in the amount of $50.00. No personal checks will be
accepted. Cash will only be accepted when petitioner hand carries documents into the Office
of the Lieutenant Governor.
SUPPORTING DOCUMENTS- Marriage Certificate, Divorce Decree, Death Certificate,
Paternity Documents, Adoption Decree, Guardianship documents, prior name change decree,
if applicable (copies acceptable).
CONSENT FORM- signed by minor child over 10 years of age
ENVELOPES- Please enclose 2 self-addressed stamped envelopes:
1 ea. #10 (regular) envelope with 1 first class stamps
1 ea. large flat manila envelope with $2.00 stamps
CORRECTIONS- Petitions with liquid paper corrections must be initialed by the notary
NOTICE REGARDING LEGAL ADVICE
The Office of the Lieutenant Governor cannot render legal advi
ce regarding name changes. We can only
answer questions related to the procedures involved in processing name changes. IF YOU HAVE
LEGAL QUESTIONS, YOU SHOULD CONTACT AN ATTORNEY.
A PETITION CONTAINING TYPOGRAPHICAL ERRORS, MISSING INFORMATION
OR OTHERWISE NOT IN CONFORMANCE WITH THESE INSTRUCTIONS WILL NOT
BE ACCEPTED FOR PROCESSING.
Form C- Rev 02/2018 Page 6
IN THE OFFICE OF THE LIEUTENANT GOVERNOR
OF THE STATE OF HAWAII
In the Matter of the Petition )
of )
)
(1) )
and (Father) )
)
for and on behalf of (Mother) )
)
)
a minor, )
)
For Change of Name )
)
(2)
)
PETITION
TO THE HONORABLE JOSHUA B. GREEN, LIEUTENANT GOVERNOR OF THE
STATE OF HAWAII:
COMES NOW and
(Father)
your Petitioners herein, and respectfully pray that an order
(Mother)
be entered herein changing the name of their minor child and in support thereof represent as follows:
I.
(Father)
(3)
That your Petitioner is
date of birth is
(petitioner)
place of birth is
(petitioner)
father’s name is
(petitioner) (Name as shown on birth certificate)
mother’s maiden name is
(First) (Middle) (Surname)
)
Form C- Rev 02/2018 Page 7
II. (Mother)
That your Petitioner is
date of birth is
(petitioner)
place of birth is
(petitioner)
father’s name is
(petitioner) (Name as shown on birth certificate)
mother’s maiden name is
(First) (Middle) (Surname)
III.
(4)
That your Petitioners are parents of the minor child herein, born on
at _
The name on the minor’s birth certificate is
IV.
(5)
That your Petitioners are now requesting that they be permitted to change the name of their minor
child to ,
for the following reason:
V.
(6)
That your Petitioner is a resident of the State of
and their current residence address is
Form C- Rev 02/2018 Page 8
(7)
WHEREFORE, your Petitioners pray that an order be entered herein changing the name of their
minor child from
to
(8)
Dated: , Hawaii
(City)
Petitioner (Father sign name in full)
Petitioner (Mother sign name in full)
STATE OF HAWAII )
)
COUNTY OF ) SS.
(Honolulu, Hawaii, Maui, Kauai)
(10) and
(Father) (Mother)
being first duly sworn on oath depose and say:
That they are the Petitioners herein, that they have read the foregoing Petition, know the
contents thereof, and that the same are true to the best of their knowledge.
(11)
Petitioner (Father sign name in full)
Petitioner (Mother sign name in full)
Subscribed and sworn to before me
this day of , 20 .
(Notary Stamp or Seal)
Notary Public, State of Hawaii
Printed Name:
My Commission Expires:
Notary Signature
Doc. Date: # Pages: Notary
Name:
Circuit Doc.
Description:
(Stamp or seal)
Page 9
FACT SHEET
(INFORMATION REGARDING THE FATHER OF MINOR CHILD)
Each Petitioner shall answer the following questions fully and completely and submit this FACT SHEET with
your Petition for Change of Name.
1.
What is the name on your Birth Certificate? What is the File No? Dated
2.
What is the name on your Certificate of Naturalization? What is the No? Dated
3.
What name appears on your social security card?
4.
What name do you use in your employment?
5.
List all of your marriages, divorces, dates and places thereof:
Married to Date of Marriage Place of Marriage
Divorced From Date of Divorce Place of Divorce
6.
List the names, date and place of birth of all your living children:
Name Date of Birth Place of Birth
7.
What is the reason for legalizing this name change?
8.
I, (Minor Child) was born in the State of Hawaii, and wish to have the name on my birth certificate
amended in the following way:
(First Name) (Middle Name) (Last Name)
Form C - Rev. 02/2018
Page 10
FACT SHEET
(INFORMATION REGARDING THE MOTHER OF MINOR CHILD)
Each Petitioner shall answer the following questions fully and completely and submit this FACT SHEET with
your Petition for Change of Name.
1.
What is the name on your Birth Certificate? What is the File No? Dated
2.
What is the name on your Certificate of Naturalization? What is the No? Dated
3.
What name appears on your social security card?
4.
What name do you use in your employment?
5.
List all of your marriages, divorces, dates and places thereof:
Married to Date of Marriage Place of Marriage
Divorced From Date of Divorce Place of Divorce
6.
List the names, date and place of birth of all your living children:
Name Date of Birth Place of Birth
7.
What is the reason for legalizing this name change?
8.
I, (Minor Child) was born in the State of Hawaii, and wish to have the name on my birth certificate
amended in the following way:
(First Name) (Middle Name) (Last Name)
Form C - Rev. 02/2018
Page 11
Name
Address
City, State, Zip Code
Telephone #
IN THE OFFICE OF THE LIEUTENANT GOVERNOR
STATE OF HAWAII
In the Matter of the Petition )
of )
)
)
and (Father) )
)
)
for and on behalf of (Mother) )
)
)
a minor, )
)
For Change of Name )
)
)
NOTICE OF CHANGE OF NAME
Upon consideration of the Petition of and
, and there appearing to me to be good reasons for
granting the same:
NOW, THEREFORE, by virtue of the authority vested in me by law and thereunto
enabling, I, Joshua B. Green, Lieutenant Governor of the State of Hawaii, do hereby give public
notice that the name of shall be changed to
upon a single
publication in the Honolulu Star-Advertiser, a newspaper of general circulation in the State of Hawaii,
published at Honolulu, Hawaii.
DATED: Honolulu, Hawaii
JOSHUA B. GREEN
Lieutenant Governor of the State of Hawaii
Form C - Rev. 02/2018
Page 12
Name:
Address:
City, State, Zip:
Telephone #:
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
LAND COURT REGULAR SYSTEM
IN THE OFFICE OF THE LIEUTENANT GOVERNOR
STATE OF HAWAII
In the Matter of the Petition )
)
of
)
)
)
and
(Father)
)
)
) ORDER
for and behalf of
(Mother)
)
)
)
a minor, )
)
For Change of Name )
)
Form C - Rev. 02/2018
Page 13
ORDER
The Notice of Change of Name of
having been published on in a newspaper of general circulation in the State of Hawaii,
I, Joshua B. Green, Lieutenant Governor of the State of Hawaii, by virtue of the authority vested in me
by law and thereunto enabling, do hereby order that the name of
be changed to
effective .
DATED: Honolulu, Hawaii
JOSHUA B. GREEN
Lieutenant Governor of the State of Hawaii
Form C - Rev. 02/2018
Page 14
The following is to be signed by the minor (over the age of ten) and returned with the Petition for change
of name.
CONSENT TO CHANGE OF NAME
I, , whose parents (Petitioners) are
and
presently residing at do hereby consent to
having my name changed from to
.
DATED:
Signature of Minor
Signature of Petitioner (Mother)
Signature of Petitioner (Father)
Fo
rm C - Rev. 02/2018