JV-124 (Rev. 11/05/2018)
Page 1 of 2
PETITION FOR
CHANGE OF NAME
DOCKET NUMBER
Trial Court of Massachusetts
Juvenile Court Department
DIVISION
1. Name of Petitioner:
2. The child's current legal name (if different from petitioner) is:
3. Child's date of birth: Child's SSN:
Child's place of birth:
Child's Address:
4. What is your relationship to the child?
5. Child's Parents: Mother Father
Name:
Address:
Telephone:
6. Reason for name change:
_______________________________________________________________
_____________________________________________________________________________________
7. Has the child ever changed his/her name prior to this petition? Yes No If yes, please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
(Attach a copy of the Name Change Judgment or Decree)
8. A copy of the child's birth certificate is attached.
WHEREFORE, the Petitioner requests that the child's name be changed as follows:
Name at present:
To be changed to:
Petitioner requests the Court to waive public notice of this petition. As reasons the petitioner states:
Mother assents to the petition to change the child's name.
(See page 2)
Father assents to the petition to change the child's name.
(See page 2)
_____________________________________________________________________________________
_____________________________________________________________________________________
Date:
(Signature of Petitioner)
(Address)
Telephone No.
