Print Form Petition for Change of Name (Page 1 of 3) Clear Form (Rev. 2/23/09) CCCO 0039 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS IN THE MATTER OF THE PETITION OF ____________________________________________________________ FOR CHANGE OF NAME TO ____________________________________________________________ } No. _____________________________________ PETITION I/We, _______________________________________________________, request the entry of an order by this Honorable Court in compliance with the provisions of 735 ILCS 5/21-101 et. seq. for a change of name and in support of this petition and under penalties for perjury as provided by Section 1-109 of the Code of Civil Procedure (735 ILCS 5/1-109) state: A. FOR MYSELF 1. My date of Birth is: __________________________, __________. 2. My place of birth was: ____________________________________________. 3. My current residence address is:___________________________________________________________________________________. I have lived in Illinois since __________________________, __________. (Insert date.) 4. I will have published notice of my intention to apply to this court for a change of name. A copy of that notice will be filed with the Clerk of Court. 5. I am 6. I have am not required to register as a sex offender under the Sex Offender Registration Act (730 ILCS 150/1 et. seq.). have not been convicted of identity theft. 7. I have have not been convicted of aggravated identity theft. 8. I have have not been convicted or placed on probation for a felony or misdemeanor in the State of Illinois or any other state. (If you have been convicted or placed on probation give details including name of offense, date of conviction or probation, sentence imposed and date of end of sentence including parole or mandatory supervised release.) __________________________________________________________ __________________________________________________________________________________________________. 9. I request the Court change my name to: ____________________________________. ____________________________________________________________________ (If petition is only filed on your behalf go to Section D, sign and complete.) B. FOR MY SPOUSE 10. My spouse’s current name is: ___________________________________; his/her date of birth is:____________________, ________. 11. My spouse’s place of birth was:____________________________________________. 12. My spouse’s current residence address is:___________________________________________________________________________. 13. My spouse has lived in Illinois since __________________________, __________. (Insert date.) 14. I will have published notice of my intention to apply to this Court for a change of name. A copy of that notice will be filed with Clerk of Court. 15. My spouse is is not required to register as a sex offender under the Sex Offender Registration Act (730 ILCS 150/1 et. seq.). 16. My spouse has has not been convicted of identity theft. 17. My spouse has has not been convicted of aggravated identity theft. 18. My spouse has has not been convicted or placed on probation for a felony or misdemeanor in the State of Illinois or any other state. (If you have been convicted or placed on probation give details including name of offense, date of conviction or probation, sentence imposed and date of end of sentence including parole or mandatory supervised release.) ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________. 19. I request the Court change my name to: ________________________________________. (OVER) (Page 2 of 3) C. (Rev. 2/23/09) CCCO 0039 B FOR MY CHILDREN 20. Name of Child Age Date and Place of Birth __________________________________________________ _______ ______________________________________ __________________________________________________ _______ ______________________________________ __________________________________________________ _______ ______________________________________ __________________________________________________ _______ ______________________________________ (Use additional sheet if more than 4 children) 21. My Relationship to the child(ren) is: ______________________________________________________________________________ (Parent, Guardian, Head of Household where child has resided for 3 years) 22. I feel it is in the best interest of the Child(ren) that a name change occur because: _______________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________. 23. The name and address of each child’s parents are: Name of Child Father Mother A. __________________________________ ___________________________________ _____________________________ B. __________________________________ ___________________________________ _____________________________ C. __________________________________ ___________________________________ _____________________________ D. __________________________________ ___________________________________ _____________________________ (If more than four children, attach additional sheet listing Name of Child, Name of Father and Mother of that child. This list should assign a letter to the child; for example child 5 should be assigned E and so forth.) Each Parent has: (The parents of a minor child whose name is sought to be changed must either consent in writing to the change of name or be given notice of the hearing date and time so tht the parent may appear and voice any objections. For each parent please place the letter that identifies the child on the line to indicate whether the parent has consented or received notice.) __________ Consented to the change of name by signing this petition; __________ Received notice of this Petition and Court Date (Bring proof of service of notice dated at least 10 days before the court date to court on hearing date.) __________ Cannot be located and has received Notice of these proceedings by Publication (Affidavit detailing efforts to locate absent parent, copy of notice provided to absent parent and proof of service of notice required to be presented in Court at hearing.) 24. I request that the Child(ren) name(s) be changed to: From: To: A. _______________________________________________ A. _______________________________________________ B. _______________________________________________ B. _______________________________________________ C. _______________________________________________ C. _______________________________________________ D. _______________________________________________ D. _______________________________________________ (OVER) (Page 3 of 3) (Rev. 2/23/09) CCCO 0039 C D. SIGNATURE Under penalties of perjury as provided in Section 1-109 of the Code of Civil Procedure (735 ILCS 5/1-109) I certify that I have read the Petition for Change of Name filed by _____________________________________________ and state all of the facts contained therein are true. _________________________________________________ __________________________________________________ Signature of Petitioner Signature of Second Petitioner _________________________________________________ __________________________________________________ Print Name Print Name _________________________________________________ __________________________________________________ Street Address Street Address _________________________________________________ __________________________________________________ City/State/Zip City/State/Zip E. AFFIDAVIT BY PERSON OTHER THAN PETITIONER State of Illinois Cook County } ss: _____________________________________________________ being duly sworn on oath deposes and says that I am acquainted with _________________________________________________________________________________________________ (Print Name of Petitioner(s)) _______________________________________________ who reside(s) at: ___________________________________________ _________________________________________________________________________________________________ who is/are the petitioner(s) in this cause, and who has/have signed this petition; that I read this petition and know the contents thereof, and the matters and things stated therein are correct to the best of my knowledge and belief. ____________________________________________________ Affiant Subscribed and sworn to before me this ____________ day of Atty. No.: __________________ Name _______________________________________________ ________________________________________, __________. ______________________________________________________ Notary Public Atty. for: ________________________________________________ Address: _________________________________________________ City/State/Zip: __________________________________________ Telephone: _____________________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS