STATE OF ILLINOIS COUNTY OF McLEAN ) ) SS ) IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUIT, McLEAN COUNTY, ILLINOIS IN THE MATTER OF THE PETITION OF ) ) ___________________________________ ) ) __________________________________ ) For Change of Name Case no. PETITION FOR CHANGE OF NAME (ADULT) 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. 2. That Petitioner now bears 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 he/she is a resident of the State of Illinois and the County of McLean in said State, and has been a resident of said state for more than six months past. 4. That he/she was born in the City of ___________________, County of_______________ and State/Country of _____________________________. 5. That Petitioner has given due notice of his/her intended application, by publication in the ___________________________________, a newspaper of general circulation published in McLean County, for three (3) consecutive weeks, a copy of which published notice with the Publisher’s certificate thereon is attached hereto, marked “Exhibit A”, and made a part hereof. 6. That Petitioner has/has not in any state or Country been convicted of sexual abuse, where the victim was under 18 years of age when the offense was committed, or indecent solicitation of a child or an adult. 7. That Petitioner is/is not required to register under the Sex Offender Registration Act (730 ILCS 150/1 et seq.). American LegalNet, Inc. www.FormsWorkflow.com 8. The Petitioner has never been convicted of the offense of Identity Theft. Wherefore, Petitioner prays that his/her name be changed from its current form to ___________________________________________ as provided by 735 ILCS 5/21 ___________________________________ Petitioner STATE OF ILLINOIS ) ) SS COUNTY OF McLEAN ) ______________________________________being first duly sworn on oath says that he/she is the Petitioner in the foregoing matter; that he/she is familiar with the matters herein contained and that the statements set forth herein are true and correct in substance and in fact. __________________________________ Petitioner Subscribed and sworn before me This____day of ____________,20__. ______________________________ Notary Public American LegalNet, Inc. www.FormsWorkflow.com