STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE _____ JUDICIAL CIRCUIT ______________________ COUNTY IN RE THE MATTER OF: ________________________________ CHANGE OF NAME TO: _________________________________ ) ) ) ) ) ) ) No. __________________________ PETITION FOR CHANGE OF NAME I, ________________________________, without the assistance of counsel, ask this Court to enter an order for change of name in compliance with 735 ILCS 5/21-101 et. seq. In support of my Petition, I state the following items are true: 1. This Court has jurisdiction over the subject matter and my person. 2. I am ____ years of age. 3. My current address is ___________________________________________________________. 4. I have lived in Illinois since _________________________________________________. 5. I have never been convicted of criminal sexual abuse of a minor, sexual exploitation of a child, indecent solicitation, or any other crime which would require registration as a sex offender in this or any other state. 6. I have never been convicted of identity theft or aggravated identity theft in this or any other state. 7. I have ______ never been convicted of a felony in this or any other state; I was convicted of a felony but _____ was pardoned _____ ten years or more years have passed since completion and discharge of my sentence. 8. The state/country of my birth is _________________________________. 9. My current full name is _______________________________________. 10. The new name which I would like the Court to give me is _______________________________ ___________________________. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com I hereby certify, under penalties as provided by law pursuant to Section 5/1-109 of the Code of Civil Procedure, that all statements set forth in this petition are true and correct to the best of my knowledge and belief. WHEREFORE, I request that the Court grant my Petition for a Change of Name. ____________________________________ Signature of Petitioner ____________________________________________________________________________________ AFFIDAVIT OF NON-PETITIONING WITNESS I, _____________________________________________________ affirm under oath that I am acquainted with the petitioner _______________________________________________. I have read and understood the contents of this petition, and affirm that all statements therein are true and correct to the best of my knowledge and belief. ____________________________________ Signature of Witness Subscribed and sworn before me on this ______ day of _________________, the year __________ _______________________________ Notary Public Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com