This form is approved by the Illinois Supreme Court and is required to be accepted in all Illinois courts. NC - R 303.6 Page 1 of 3 ( 01 /1 9 ) STATE OF ILLINOIS , REQUEST FOR NAME CHANGE (ADULT) For Court Use Only CIRCUIT COURT COUNTY Instructions Directly above, enter the county name where you will file this case. Request of: Enter your current name. DO NOT enter a Case Number, the Circuit Clerk will add it. Your current name ( First, middle, last name ) Case Number In 1, enter your complete current name. I ask the court to enter an order to change my name, and I state: 1. My current name is: In 2, enter the new full name you would like. First Middle Last 2. I wish my name to be changed to: First Middle Last In 4, enter the date you started living in Illinois. 3 . My address is listed at the end of this Request . 4 . I have lived continuously in Illinois for at least 6 months beginning : In 5, enter your date of birth Date 5 . My birth date is: In 6, enter the city, county, state, and country where you were born. Date 6 . My place of birth i s: City County State /Province Country In 7-9, check the boxes that apply to your criminal history. 7. I have have not been adjudicated or convicted of a felony or misdemeanor in Illinois or any other state for which a pardon has not been granted. In 10, 11, and 12 check whether you have or have not been convicted or put on probation for the crime listed. 8. I do do not have an arrest for which charges have not been filed. 9. I do do not have a pending felony or misdemeanor charge. If you checked 223have224 in 10 or 11 and have not been pardoned, the court cannot give you a name change . 10 . I have have not been convicted of or placed on probation for a crime which require s me to register as a sex offender in Illinois or any other state. 11 . I have have not been convicted of or placed on probation for identity If you checked 223have224 in 12 and have not been pardoned or have not completed your probation or sentence over 10 years ago, the court may not give you a name change . theft or aggravated identity theft in Illinois or any other state. 12 . I have have not been convicted of or placed on probation for a felony in Illinois or any other state. American LegalNet, Inc. www.FormsWorkFlow.com Enter the Case Number given by the Circuit Clerk: NC - R 303.6 Page 2 of 3 (01 /1 9 ) In 13, describe what you were convicted of or placed on probation for, if you checked 223have224 in 10, 11, or 12. If you run out of space, use a separate piece of paper. 13. If you checked "have" in 10, 11, or 12 complete the following: Description of Felony or Misdemeanor Date of Conviction or Probation Sentence Received (include parole and supervised release) Date Sentence Completed Pardoned? (Yes or No) Under the Code of Civil Procedure, 735 ILCS 5/1-109 , making a statement on this form that you know to be false is perjury, a Class 3 Felony. I certif y that everything in the Request for Name Change (Adult) is true and correct. I understand that making a false statement on this form is perjury and has penalties provided by law under 735 ILCS 5/1 - 109 . /s/ Your Signature Street Address If you are completing this form on a computer, sign your name by typing it. If you are completing it by hand, sign and print your name. Print Your Name City, State, ZIP Telephone Enter your complete current address and telephone number. If disclosing your address would put you or your household at risk, you may use another address. That address must be one at which you can receive mail about the case. I am using an alternative a ddress because disclosing my address would put me or my household at risk. GETTING COURT DOCUMENTS BY EMAIL: If you agree to receive court documents by email, check the box below and enter your email address. You should use an email account that you do not share with anyone else and that you check every day. If you do not check your email every day, you may miss important information or notice of court dates. Other parties may still send you court documents by mail. I agree to receive court documents at this email address during my entire case. Email American LegalNet, Inc. www.FormsWorkFlow.com Enter the Case Number given by the Circuit Clerk: NC - R 303.6 Page 3 of 3 (01 /1 9 ) NOTE This section must be filled out by someone else, not by you. VERIFICATION BY WITNESS I, Witness: Enter your full name. First Middle Last certify that what is stated above and on the Request for Name Change (Adult) is true and correct Under the Code of Civil Procedure, 735 ILCS 5/1-109 , making a statement on this form that you know to be false is a Class 3 Felony. to the best of my knowledge and belief. I understand that making a false statement on this form is perjury and has penalties provided by law under 735 ILCS 5/1 - 109 . Witness Signature Street Address Witness: Sign and print your name. Witness: Enter your complete address and telephone number. Print or Type Name City, State, Zip Telephone American LegalNet, Inc. www.FormsWorkFlow.com