Fillable REQUEST FOR NAME CHANGE - CHILD INFORMATION (Illinois)

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REQUEST FOR NAME CHANGE - CHILD INFORMATION (Illinois)

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The REQUEST FOR NAME CHANGE - CHILD INFORMATION (Illinois) form is 2 pages long and contains:

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  • 4 check-boxes
  • 29 other fields

Country of origin: US
File type: PDF

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This form is approved by the Illinois Supreme Court and is required to be accepted in all Illinois Circuit Courts.
STATE OF ILLINOIS,
CIRCUIT COURT
COUNTY
REQUEST FOR NAME CHANGE -
CHILD INFORMATION
For Court Use Only
Instructions
REQUEST OF:
Directly above, enter
the county name
where you will file this
case.
First, Middle, Last Name
TO CHANGE NAMES OF MINOR CHILDREN
Case Number
Enter the name of the
person asking the
court to change the
names of minor
children.
DO NOT enter a Case
Number, the Circuit
Clerk will add it.
In 1a, enter the
complete current name
of 1 minor child whose
name you wish to
change. This should be
the full name of the
child listed on their
birth certificate.
In 1b-c, enter the
child’s date and place
of birth.
In 1d, if disclosing the
child's address would
put the child or a
member of the
household at risk, you
may use another
address. That address
must be one at which
you can receive mail
about the case.
In 2, select your
relationship to the
minor child. If your
relationship is not
listed, you cannot ask
the court to change the
name of the child.
If you checked “has” in
3a or 3b and the child
has not been pardoned,
the court cannot give
you a name change.
If you checked “has” in
3c and the child has not
been pardoned or has not
completed probation or
sentence over 10 years
ago, the court may not
give you a name change.
1.
I am providing the following information about the minor child:
a.
Name:
First
Middle
Last
b.
c.
d.
Date of birth is:
Date
Place of birth:
City
Address is:
County
State/Province
Country
Street, Apt #
City
State
ZIP
I am using an alternative address because disclosing my address would put the child
or a member of the household at risk.
2.
My relationship to the child is:
parent with custody/parental decision making responsibility; OR
guardian with legal custody; OR
the child has lived in my home for 3 years and is recognized as my adopted child.
3.
I am providing the following information about the child’s criminal history:
a.
The child
has
has not been convicted of or placed on probation for a crime
which requires them to register as a sex offender in Illinois or any other state.
b.
The child
has
has not been convicted of or placed on probation for identity
theft or aggravated identity theft in Illinois or any other state.
c.
The child
has
has not been convicted of or placed on probation for a felony
in Illinois or any other state.
NCM-CI 2004.3
Page 1 of 2
(01/19)
In 4, select all the
reasons it is in the
child's best interest to
change their name.
Use “Other” to add
other reasons.
Enter the Case Number given by the Circuit Clerk: ____________________
4.
It is in the best interest of the child that their name be changed because (check all that apply):
I wish to have the child’s name changed.
The child wishes to have their name changed.
Other:
5.
I am providing the following information about other parents (do not include yourself or
In 5, if there is another
parents whose rights as parents have been terminated by a court order).
parent, list their name
and address. If not,
None
check "None."
Name and address of other parent:
First
Middle
Last
Street, Apt #
City
State
ZIP
In 6, if the parent listed
6.
The other parent listed above agrees to this name change.
above agrees to this
I don’t know
name change, have
them sign their name in
No
front of an Illinois
Yes (If yes, have the other parent sign below)
notary public if they
are not going to be at
I,
the court date.
First
Middle
Last
consent to the child’s name change.
Signature (sign in front of an official Illinois notary public)
Notary Public
DO NOT complete
State of Illinois
this section. The notary
County of
will complete it.
Signed and sworn to before me on
by
.
Date
Name
Seal
Signature of Notary
In 7a or 7b, if there is
7.
There is a second parent or person who is not the parent with physical custody of the child.
a second parent or a
a.
There is a second parent.
person who is not the
parent with physical
Yes (If yes, fill out and attach the Request for Name Change - Additional Parent form.)
custody of the child,
No
check "Yes" and fill
out and attach the
Request for Name
Change - Additional
b.
There is a person who is not the parent with physical custody of the child.
Parent form. If not,
Yes (If yes, fill out and attach the Request for Name Change - Additional Parent form.)
check "No."
No
NCM-CI 2004.3
Page 2 of 2
(01/19)
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REQUEST FOR NAME CHANGE - CHILD INFORMATION (Illinois)

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Completed 20 January 2021

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