IN THE CIRCUIT COURT FOR THE SIXTEENTH JUDICIAL CIRCUIT DE KALB COUNTY, ILLINOIS IN THE MATTER OF THE PETITION OF ) ) ) ________________________________ ) NO. __________________________________ PETITION FOR CHANGE OF NAME TO THE HONORABLE JUDGE OF THE CIRCUIT COURT: Your petitioner __________________________________________ respectfully shows that he/she is a resident of the State of Illinois, and has resided in the County of DeKalb in said State, for more than six months prior to the filing of this petition; that he/she desires to change his/her name, according to the provisions of the Statute in such case made and provided, and now, in that behalf, respectfully shows that he/she now bears the name of: ________________________________________ and is known and called by this name; that he/she desires to assume the name of: _______________________________________________ by which he/she may be hereafter known and called. That his/her respective place of nativity and age is as follows: ____________________________ ___________________________________________________________________________________. That he/she has resided in the State of Illinois for _______ years last past. That he/she has given notice of this, his/her intended application by publication in _______________________________________, a newspaper published in DeKalb County of general circulation, for three successive weeks, a copy of which published notice, with the certificate of the publisher thereon, is hereto annexed and made a part of this petition. WHEREFORE, your Petitioner prays, the premises being considered, that his/her name be changed from its present form to _________________________________________________________ as provided by Statute, and that he/she hereafter be known and called by the last aforesaid name, and that he/she has such other or future relief in the premises as this Honorable Court shall seem meet, according to law. Attorney for Petitioner Petitioner (Print Name) Attorney Number Address Address City/State/Zip Telephone STATE OF ILLINOIS COUNTY OF DE KALB ) ) SS AFFIDAVIT ____________being duly sworn on oath deposes and says that he/she is acquainted with ______________________________ the petitioner in this cause, who has signed this petition; that he/she has hereby read this petition, and knows the contents thereof, and that the matters and things herein stated are true. Sworn and subscribed to before me ____________________, ________. Affiant Deputy Clerk-Notary Public C:\FORMS\CI000034.CIV Rev.: 7/7/06 American LegalNet, Inc. www.USCourtForms.com