FORM CC-1427 (MASTER, PAGE ONE OF TWO) 07/18
APPLICATION FOR CHANGE OF NAME (MINOR) Case No. ....................................................
Commonwealth of Virginia Va. Code § 8.01-217
In the Circuit Court of the [ ] City [ ] County of
..........................................................................................................
In re: .....................................................................................................................................................................
(MINOR’S PRESENT NAME)
FIRST MIDDLE LAST SUFFIX
COMES NOW, the applicant, and after being duly sworn states under oath as follows:
1. Minor’s name is stated accurately above and [ ] has [ ] has not been previously changed. If so, court order is attached.
2. Applicant’s Name:
.............................................................................................................................................
FIRST MIDDLE LAST SUFFIX
2a. Residence Address: .......................................................................................................................................
STREET ADDRESS
........................................................................................................................................................................
CITY STATE ZIP CODE COUNTRY
2b. Mailing Address: ..........................................................................................................................................
IF DIFFERENT FROM RESIDENCE ADDRESS
3. Relationship to minor: [ ] Parent [ ] Guardian [ ] Next Friend [ ] ....................................................................
Provide the following information about the minor.
4. Date and Place of Birth:
......................................................................................................................................
DATE OF BIRTH PLACE OF BIRTH
5. City or county of residence: .................................................................................................................................
6. Address if different from applicant’s: ....................................................................................................................
STREET ADDRESS
........................................................................................................................................................................
CITY STATE ZIP CODE COUNTRY
7. Full Names and Addresses of Parents
7a. Full Name: ...............................................................................................................................................
FIRST MIDDLE MAIDEN (IF APPLICABLE) CURRENT LAST SUFFIX
Residence Address: ............................................................................................................................................
STREET ADDRESS
........................................................................................................................................................................
CITY STATE ZIP CODE COUNTRY
Mailing Address: ...............................................................................................................................................
IF DIFFERENT FROM RESIDENCE ADDRESS
7b. Full Name: ...............................................................................................................................................
FIRST MIDDLE MAIDEN (IF APPLICABLE) CURRENT LAST SUFFIX
Residence Address: ............................................................................................................................................
STREET ADDRESS
........................................................................................................................................................................
CITY STATE ZIP CODE COUNTRY
Mailing Address: ...............................................................................................................................................
IF DIFFERENT FROM RESIDENCE ADDRESS
Answer the following questions by checking appropriate “Yes” or “No” box and providing information as requested.
8. Has the minor ever been convicted of a felony?
......................................................................... [ ] Yes [ ] No
9. Is the minor currently incarcerated? **
..................................................................................... [ ] Yes [ ] No
If yes, indicate facility name:
........................................................................................................................
Facility Location:
........................................................................................................................................
10. Is the minor a probationer with any court? **
............................................................................ [ ] Yes [ ] No
If yes, indicate court name:
...........................................................................................................................
11. Is the minor a person for whom registration with the Sex Offender and [ ] Yes [ ] No
Crimes Against Minors Registry is required? **
If yes, indicate court where conviction occurred that resulted in the requirement to register:
..................................
12. Reason for name change application
..........................................................................
[ ] Supplemental sheet attached
** No application of a probationer, incarcerated person, or person for whom registration with the Sex Offender and Crimes
Against Minors Registry is required shall be accepted unless the Court finds good cause exists for consideration of such
application under the reasons alleged in the application for the requested change of name. Attach explanatory documentation
to the application.
.........................................................................
Rockingham
FIRST (MINOR'S PRESENT NAME)
LAST
MIDDLE
SUFFIX
FIRST MIDDLE LAST
MAIDEN (IF APPLICABLE)
MAIDEN (IF APPLICABLE)
