700-00123 – Petition Change Name of Minor (06/2020) Page 1 of 2
STATE
OF
VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
In re:
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:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
700-00123 – Petition Change Name of Minor (06/2020) Page 2 of 2
I swear or affirm that the facts set forth in this petition are true and correct to the best of my knowledge and
belief.
On:
Date
At:
Signature of Petitioner
City, County and State
Printed Name
Being over the age of 14, I consent to the name change: ____________________________________________
Signature of Minor
Signed and sworn to before me:
Part II. Consent
I, _______________________________________ whose relationship with the minor is that of
_________________________________________ consent to the change of name of the minor from
_________________________________________ to the new name of _______________________________
At ____________________________ on this ____________day of ______________________, 20_________
______________________________________________
Signature
______________________________________________
Printed Name
______________________________________________
Mailing Address
______________________________________________
Telephone/Email
Signed and sworn to before me:
Note:
15 V.S.A. § 812 states that the name of a minor if over fourteen years of age shall not be changed without this consent
given in court.