JDF 389 R 5 - 1 8 PETITION FOR CHANGE OF NAME (70 YEARS OF AGE OR OLDER) County Court District Court County, Colorado Court Address: I n the Matter of the Petition of : F or a Change of Name to : COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E - mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom PETITION FOR CHANGE OF NAME ( 70 YEARS OF AGE OR OLDER ) 1. My current full name is . First Name Middle Name Last Name 2. I wish to change my name to . First Name Middle Name Last Name 3. I am a resident of County, Colorado. My date of birth is . 4. I am at least 70 years of age and I attest under penalty of perjury that I have not been convicted of a felony or adjudicated as a juvenile delinquent for an offense that would constitute a felony if committed by an adult in any state or under federal law. 5. I am seeking a name change to harmonize name discrepancies necessary to be iss ued an identification card in Colorado. This change would be proper and not detrimental to the interest of any other person. 6. My certified, fingerprint - based criminal history record check from the FBI is attached as Exhibit A and my certified, fingerprin t - based criminal history record check from the CBI is attached as Exhibit B. Both are dated within 90 days of the filing of this Petition pursuant to 247 13 - 15 - 101 , C.R.S. o r I have attached the following: (1) Exhibit A CBI/FBI notices that my fingerprint - based criminal history record checks were inconclusive because my fingerprints were unreadable or not discernible; and (2) Exhibit B Name - based criminal history record check with all previously used names from the CBI . Exhibits B is dated within 90 days of the filing of this Petition pursuant to 247 13 - 15 - 101, C.R.S. 7. I ask the Court to order the name change. I, swear/affirm under oath that I have read the foregoing Petition and that the statements contained in the Petition are true to the best of my knowledge. By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. By checking this box, I am acknowledging that I have made a change to the original content of this form. VERIFICATION AND ACKNOWLEDGEMENT I ask the court to order the name change. I , swear/affirm under oath that I have read the foregoing Petition and that the stateme nts contained in this Petition are true to the best of my knowledge. Date: Signature of Petitioner Address City State Zip Code Telephone #: (home) (work) (cell) Subscribed and affirmed, or sworn to before me in the County of , State of , this day of , 20 . M y Commission Expires: Deputy Clerk/Notary Public American LegalNet, Inc. www.FormsWorkFlow.com