CC- 221 STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 17TH JUDICIAL CIRCUIT COUNTY OF WINNEBAGO FILE STAMP IN THE MATTER OF THE PETITION OF ________________________________ Case No. ___________________ Current Name PETITION FOR NAME CHANGE I, ______________________________________________, ask this Court to change my name. In support of my Petition, I state the following items are true: 1. This Court has jurisdiction over the subject matter and my person. 2. I am ________________ years old. 3. My current address is: ________________________________________________________________ __________________________________________________________________________________. 4. I have lived in Illinois for at least 6 consecutive months before I filed this petition. 5. The state/county of my birth is:________________________________________. 6. I have never been convicted of a felony in this state or any other state. or I have been convicted of a felony in this state or another state, but at least 10 years have passed since the completion and discharge of my most recent sentence. or I have been convicted of a felony in this state or another state, but I was pardoned for the offense on ________________________________. 7. I have never been convicted of any of the following offenses: ________________________________________ Identity Theft, Aggravated Identity Theft, felony or misdemeanor Criminal Sexual Abuse of a Minor, felony or misdemeanor Sexual Exploitation of a Child, felony or misdemeanor Indecent Solicitation of a Child, or any other offenses which would require me to register under the Sex Offender Registration Act. 8. My current full name is:_______________________________________________________________________. 9. The new name I would like the court to give me is:__________________________________________________. WHEREFORE, I, request that the Court grant my Petition for a Name Change. __________________________, Plaintiff Under penalties as provided by law pursuant to Section 5/1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief as to such matters the undersigned certifies as aforesaid that she/he verily believes the same to be true. __________________________, Plaintiff Rev 3/11 American LegalNet, Inc. www.FormsWorkFlow.com