STATE OF ILLINOIS ) ) SS COUNTY OF LAKE ) IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT, LAKE COUNTY, ILLINOIS IN THE MATTER OF THE PETITION OF ________________________________ A Minor by Parent or Guardian ________________________________ For Change of Name ) ) ) ) ) ) Gen. No. _______________ PETITION FOR NAME CHANGE (MINOR) To the Honorable Judge of the above-named Court; Your Petitioner _____________________________________ respectfully represents as follows: 1. That Petitioner desires a change of name, according to the provisions of 735 ILCS 5/21-101. 2. That Petitioner Minor now bears or holds the name of ______________________________, by which he / she has been and now is known and called, and he / she seeks to assume the name of ___________________________________, by which he / she may hereafter be known and called. 3. That (a) the minor resides at _________________________________________________, (b) minor has lived in this State for _________________________________. 4. That said minor was born in the City of __________________, County of _______________ and State/Country of ________________________. 5. That Petitioner has given reasonable notice of hearing on this Petition to any parent of the minor child whose parental rights have not been previously terminated and any person who has physical custody of the minor child in the following manner: By mailing a copy of this Petition and Notice of hearing thereon to the last known address of each person entitled to notice by certified U.S. Mail, return receipt requested. By personally delivering a copy of this Petition and Notice of hearing thereon upon each person entitled to notice through the local Sheriff or other authorized person. CV/15 171-113 rev 2/02 pg 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Other (explain)_______________________________________________________ ______________________________________________________________________ Wherefore, Petitioner prays that the minor child’s name be changed from its current form to ___________________________________________________ as provided by 735 ILCS 5/21. ___________________________________ Petitioner Mother or Guardian/Parent (if under 18) ___________________________________ Petitioner Father or Guardian/Parent (if under 18) STATE OF ILLINOIS ) ) SS COUNTY OF LAKE ) ________________________________________, being duly sworn on oath says that he / she is the Petitioner in the foregoing matter; that he / she is familiar with the matters therein contained and that the statements set forth herein are true and correct in substance and in fact. ___________________________________ Petitioner ___________________________________ Petitioner Subscribed and sworn to before me this _____ day of _________________________, 20_____. ______________________________________ Notary Public CV/15 171-113 rev 2/02 pg 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com