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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL (Pinellas County Clerk of the Circuit Court and Comptroller)

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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT
IN AND FOR PASCO AND PINELLAS COUNTIES, FLORIDA
IN RE: THE NAME CHANGE OF
CASE NO.: _______________________
________________________________, UCN: ________________________
Petitioner.
__________________________________/
AFFIDAVIT IN COMPLIANCE WITH SECTION 68.07(3)(i), FLORIDA STATUTES
“In conformity with FS 68.07(3)(i), I ______________________[Petitioner] am amending my
Petition to include the following sworn statement:”
[ ] I have been required to register as a sexual predator under s. 775.21, Fla. Stat., or sexual
offender under s. 943.0435, Fla. Stat.
[ ] I have not been required to register as a sexual predator under s. 775.21, Fla. Stat., or
sexual offender under s. 943.0435, Fla. Stat.
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in
this affidavit and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.
Dated: Signature
STATE OF FLORIDA
COUNTY OF
Sworn to or affirmed and signed before me on by .
NOTARY PUBLIC or DEPUTY CLERK
[Print, type, or stamp commissioned name of notary or clerk.]
____ Personally known
____ Produced identification
Type of identification produced
OR
SWORN TO IN OPEN COURT before the undersigned, this ____ day of ______________, 20_____.
______________________________
CIRCUIT JUDGE or Judicial Officer
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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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