IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT KANE COUNTY, ILLINOIS Case No. IN THE MATTER OF THE PETITION OF: Your Name File Stamp PETITION FOR NAME CHANGE (SELF) TO THE HONORABLE JUDGE OF THE COURT: The Petitioner, , respectively represents as follows: 1. That Petitioner desires a change of name, according to the provisions of 735 ILCS 5/21-101 et. seq. 2. That Petitioner now bears or holds the name of is known and called, and he/she seeks to assume the name of hereafter be known and called. 3. That he/she is resident of the State of Illinois, County of Kane, and has been a resident of the State for more than six months prior to the filing of this Petition. 4. That he/she was born in the City of State/Country of , by which he/she has been and now , by which he/she may , County of , and . 5. That Petitioner has given due notice of his/her intended application by publication in the ,a newspaper of general publication published in Kane County, for three (3) consecutive weeks after filing, with the first publication beginning at least six (6) weeks before the scheduled court date, with a copy of the Certificate of Publication attached hereto and made part of the Order granting the Petition. 6. That Petitioner has not in any State ever been convicted of identity theft, aggravated identity theft, felony misdemeanor criminal sexual abuse when the victim of the offense at the time of its commission was under 18 years of age, felony or misdemeanor sexual exploitation of a child, felony or misdemeanor indecent solicitation of a child, felony or misdemeanor indecent solicitation of an adult, or any other offense for which a person is required to register under the Sex Offender Registration Act in this State or any other State who has not been pardoned. 7. That Petitioner has not been convicted of any other felony not listed in paragraph 6 above, in this State or any other State, unless 10 years has passed since completion and discharge from his or her sentence or been pardoned. Wherefore, the Petitioner prays that his/her name be changed from its present form to , as provided by Statute, that he/she hereafter be known and called by that name, and that he/she have such other or further relief as this Court may order. Under penalties as provided by law pursuant to 735 ILCS 5/1-109, the undersigned certifies that the statements set forth in this petition are true and correct, except as to matters to be on information and belief and as to such matters the undersigned certifies that he/she believes the same to be true. Attorney/Pro Se: Address: City, State, Zip: Telephone No.: Atty. Registration No.: Petitioner's Signature: Address: City, State, Zip: Telephone No.: P2-PN-005 (09/08) American LegalNet, Inc. www.FormsWorkflow.com