STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 17TH JUDICIAL CIRCUIT COUNTY OF WINNEBAGO IN THE MATTER OF CC- 283 FILE STAMP ________________________________ Minor's Current Name By ______________________________________________ Name of Parent/Guardian filing on behalf of the Minor Case number given at Case No. ___________________ time of filing PETITION FOR NAME CHANGE OF A MINOR ____________________________, a minor, by, ______________________________, his/her _____________________, respectfully request that this Court change his/her name. In support of this petition, it is stated that the following items are true: 1. This Court has jurisdiction over the subject matter and the minor. 2. The minor who is the subject of this petition is ______ years old. 3. The minor's current address is: ________________________________________________________________. 4. The current address of minor's (list all known): [ ] Mother: _____________________________________________________________________________. Father: ______________________________________________________________________________. Other person(s) having custody:__________________________________________________________. [] The other parent/custodian's whereabouts are unknown � I intend to publish notice of this petition. (Subject to Court Approval) 5. The minor has lived in Illinois for at least 6 consecutive months before this petition was filed. 6. The state/county of the minor's birth is: __________________________________________________________. 7. The minor [ ] has or [ ] has not been previously convicted of a criminal offense. 8. The minor's current full name is: _______________________________________________________________. 9. The new name minor would like the Court to recognize is: ___________________________________________. WHEREFORE, it is requested that the Court grant this Petition for a Name Change of a Minor ______________________________, a minor, by, __________________________________. Under penalties as provided by law pursuant to Section 5/1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief as to such matters the undersigned certifies as aforesaid that she/he verily believes the same to be true. ______________________________, a minor, by, __________________________________. American LegalNet, Inc. www.FormsWorkFlow.com