STATE OF SOUTH DAKOTA COUNTY OF _______________ ) )SS: ) IN CIRCUIT COURT ____________ JUDICIAL CIRCUIT ************************************************************************************ In the Matter of the Petition regarding ) ) CIV.___________ ________________________________ ) (Birth Certificate Name), A Minor Child. ) VERIFIED PETITION ) FOR NAME CHANGE OF A For a Change of Name to ) MINOR CHILD ) (UNCONTESTED) ________________________________ ) (Proposed Name) ) ************************************************************************************ COMES NOW Petitioner and does hereby state, under oath, as follows: 1. My current full name is as follows:_________________________________________________. 2. The minor child's name, as it appears on their birth certificate, is as follows: _______________ ______________________________________________. 3. The minor child's date of birth is _______________________ and the child's gender at birth was: male / female. 4. The minor child was born in ________________, _______________ County, State of _____________________________. 5. My relationship to the minor child named above is ________________________. 6. The full name of the minor child's other parent is ______________________________________ and the last known address for this parent is__________________________________________ ____________________________________________________. 7. I currently reside at _________________________________________________ which is located in ___________________, ______________ County within the State of South Dakota. 8. I have been a resident of ___________________ County since ______________. Page 1 of 4 UJS-030 Verified Petition For Name Change of a Minor Child Rev. 06/2011 American LegalNet, Inc. www.FormsWorkFlow.com 9. The minor child named above currently resides at _________________________ which is located in ________________, _________________ County within the State of South Dakota and has resided there since _______________. 10. (a) During the past five years the child has lived with the following individuals, during the dates indicated and in the designated areas: Caretaker's Name _________________________ _________________________ _________________________ Dates _____________________ _____________________ _____________________ County/State _________________________ _________________________ _________________________ (b) There has/has not (circle one) been prior court proceedings regarding the custody of the child. If so, that action took place in ___________County, ___________ State in the year ____________. If there has, please provide the most current order. There is/is not (circle one) a current pending court proceeding regarding the custody or visitation of the child. If so, that action is in ______________ County, _________________ State and was commenced _______________________. (c) Other than the parents of the minor child, no one has ever had legal custody of this child except ________________________ (if none, so state). 11. The full maiden name of the child's mother, as it appears on the child's birth certificate, is _________________________________________________________________. 12. The full name of the child's father, as it appears on the child's birth certificate, is (if the father's name is not listed on the birth certificate, enter "N/A") _______________________________ __________________________________________. 13. The mother's date of birth is ____________________ and she was born in _________________, _____________________ County, State of ________________________. Page 2 of 4 UJS-030 Verified Petition For Name Change of a Minor Child Rev. 06/2011 American LegalNet, Inc. www.FormsWorkFlow.com 14. The father's date of birth is ______________________ and he was born in _________________, _____________________ County, State of ________________________. 15. I am requesting that the child's name be changed from _________________________________ to _________________________________________________ on the child's birth certificate because: ______________________________________________________________________ _____________________________________________________________________________. 16. This Petition is made in good faith. I do not intend to defraud anyone, and it is not done for the purpose of hiding my child's identity from any person, creditor or governmental agency of any kind or as to avoid discovery by such person, creditor or governmental agency. WHEREFORE, I pray that the court set this matter for hearing, and that upon such hearing, enter an order changing the name of the minor child from _______________________ ____________________________________ to _________________________________________. DATED this _______ day of _______________________, 20______. ____________________________________ Petitioner (Signature) ____________________________________ Print your name ____________________________________ Street address ____________________________________ City, State, ZIP code ____________________________________ Telephone number Page 3 of 4 UJS-030 Verified Petition For Name Change of a Minor Child Rev. 06/2011 American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION STATE OF SOUTH DAKOTA COUNTY OF ________________ ) : SS ) Petitioner, being first duly sworn, deposes and states that he or she verifies the facts expressed within the Verified Petition for Name Change of Minor Child are true. Dated this ______ day of ___________________, 20_____. _____________________________________ Petitioner's Signature Subscribed and sworn to before me this ______ day of ______________, 20____. _____________________________________ Notary Public/Clerk of Court (SEAL) If Notary, my commission expires:_____________ Page 4 of 4 UJS-030 Verified Petition For Name Change of a Minor Child Rev. 06/2011 American LegalNet, Inc. www.FormsWorkFlow.com