Petition for Change of Name IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION (01/22/16) CCCO N039 A In the Matter of the Petition of Case No. for Change of Name to PETITION FOR CHANGE OF NAME 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 year of birth is: ______ 2. My place of birth was: ____________________________ 3. My current residence address is: 4. 5. 6. 7. 8. I have lived in Illinois since (Insert date) _________ 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. I am am not required to register as a sex offender under the Sex Offender Registration Act (730 ILCS 150/1 et. seq.). I have have not been convicted of identity theft. I have have not been convicted of aggravated identity theft. 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 the 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. has has not been convicted of aggravated identity theft. 17. My spouse 18. My spouse has has not been convicted or placed on probation for a felony or misdemeanor in the State DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 3 Petition for Change of Name (Rev. 01/22/16) CCCO N039 B 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: C. FOR MY CHILDREN 20. Name of Child Age Year 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 A. B. C. D. Father Mother (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 that 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). DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 2 of 3 Petition for Change of Name (Rev. 01/22/16) CCCO N039 C 24. I request that the Child(ren) name(s) be changed to: From: A. B. C. D. D. SIGNATURE To: A. B. C. D. Under penalties of perjury as provided is 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 Print Name Street Address City/State/Zip Code Signature of Petitioner Print Name Street Address City/State/Zip Code E. AFFIDAVIT BY PERSON OTHER THAN PETITIONER STATE OF ILLINOIS COUNTY OF COOK 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. Atty. No.: ________________ Name: Atty for: Address: City: ______________________ Primary Email: Secondary Email: Tertiary Email: DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 3 of 3 Affiant Subscribed and sworn before me on this date: ________________ Notary Public State: ____ Zip: ________ Telephone: ________________________