700-00123 – Petition Change Name of Minor (06/2020) Page 1 of 2
PE
TITION TO CHANGE NAME OF MINOR
Part I. Request for Change of Name
The undersigned represents as follows:
That the minor's name is: _____________________________________________________________
That the minor was born at ________________________________________ on _________________
town/city/state date of birth
That the parents of the minor are:
Name: __________________________________ Name: _________________________________
Address: ________________________________ Address: _______________________________
That the guardian, if any, for the child was appointed by ______________________________________
and has the following name and address:
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
Name of court: ____________________________ Address: _______________________________
That my relationship to the child is: ☐ Parent ☐ Guardian
That the name I wish the minor to be known as is ____________________________________________
I would like the minor’s birth certificate changed: ☐ YES ☐ NO
That the reason for changing the minor’s name is as follows:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________