Print Form Clear Form State of Florida Department of Health Bureau of Vital Statistics Report of Legal Change of Name (Important - Read Information and Instructions before Completing this Form) STATE OF FLORIDA ) Docket or File Number: ___________________________ Date of Court Order: ______________________________ Middle Maiden Last, if Female Legal Last County of _______________________________ ) First NAME as Decreed by Court: _______________________________________________________________________________________________ Name of Petitioner: _______________________________________________________________________________________________________ First Middle Last Petitioner's Relationship to Person Whose Name Has Been Changed: _______________________________________________________________ Mailing Address of Petitioner: ______________________________________________________________________________________________ Street City State Zip Code Name of Attorney, if applicable: ____________________________________________________________________________________________ First Middle Last Attorney's Mailing Address: _______________________________________________________________________________________________ Street City State Zip Code Signed and Sealed by ______________________________________________________ Signature of Clerk of Court Date: __________________________________ Persuant to section 68.07(4) , on filing the final judgment, the clerk shall, if the birth occurred in this state, send a report of the judgment to the Department of Health, Office of Vital Statistics. The form shall contain sufficient information to identify the original birth certificate of the person, the new name, and the file number of the judgment. MAIL COMPETED AND CERTIFIED FORMS TO: Department of Health, Office of Vital Statistics, P. O. Box 210, Jacksonville, Florida 32231-0042, ATTN: Corrections Unit. Provide the following information to identify the birth certificate of the person whose name has been changed. Name at Birth: ___________________________________________________________________________________________________________ First Middle Last Maiden, if Female Subsequent Name Change, if applicable: ______________________________________________________________________________________ First Middle Last Maiden, if Female Date of Birth: ______________________________ Place of Birth: ___________________________________________________________ City County State Full Name of Mother, including Maiden Last: __________________________________________________________________________________ First Middle Maiden Last DH 427, 7/06 (Replaces 7/03 edition which may be used) American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS Please type using black ribbon. Alteration of information by us of correction fluid or other methods will make this form unacceptable for filing by Vital Statistics and the form will be returned If the person whose name has been changed is female, please list both her legal maiden last name and her legal last name under "Name as Decreed by Court." If name change is to restore a maiden surname, this report will not be attached to the original birth record, but will be retained in the files of the Office of Vital Statistics. PHOTOCOPIES OF THIS FORM WILL NOT BE ACCEPTED by Vital Statistics and will be returned. To obtain a supplies of this form, submit your request specifying the quantity desired in writing to the Office of Vital Statistics, P. O. Box 210, Jacksonville, Florida 32231-0042, ATTN: Administrative Services. DH 427, 7/06 (Replaces 7/03 edition which may be used) American LegalNet, Inc. www.FormsWorkFlow.com