This form is approved by the Illinois Supreme Court and is required to be accepted in all Illinois Circuit Courts. NCM - CI 2004.2 Page 1 of 2 (0/18) STATE OF ILLINOIS , REQUEST FOR NAME CHANGE - CHILD INFORMATION For Court Use Only CIRCUIT COURT COUNTY Instructions Directly above, enter the county name where you will file this case. REQUEST OF : Enter the name of the person asking the court to change the names of minor children. First, Middle, Last Name Case Number DO NOT enter a Case Number, the Circuit Clerk will add it. TO CHANGE NAMES OF MINOR CHILDREN In 1a, enter the complete current name of 1 minor child whose name you wish to change. This should be the full name of the child listed on their birth certificate. You should bring the child's birth certificate with you to court. 1. I am providing the following information about the m inor c hild : a. N ame: First Middle Last b . Date of birth is: Date c . Place of birth: City Count y State /Province Country In 1b, enter the child222s date of birth. d. A ddress is: Street , Apt # City State ZIP In 1c, enter the child222s place of birth. In 1d, enter the child222s complete current address. 2. My relationship to the child is: parent with custody/ parental decision making responsibility ; OR guardian with legal custody; OR In 2, select your relationship to the minor child. If your relationship is not listed, you cannot ask the court to change the name of the child. the child has lived in my home for 3 years and is recognized as my adopted child. In 3a, 3b, and 3c check whether the child has or has not been convicted or put on probation for the crime listed. 3 . I am providing the following information about the c hild 222 s criminal history: a. The child has has not been convicted of or placed on probation for a crime which requires them to register as a sex offender in Illinois or any other state. b. The child has has not been convicted of or placed on probation for identity If you checked 223has224 in 3a or 3b and the child has not been pardoned, the court cannot give you a name change. theft or aggravated identity theft in Illinois or any other state. c. The child has has not been convicted of or placed on probation for a felony in Illinois or any other state. If you checked 223has224 in 3c and the child has not been pardoned or has not completed probation or sentence over 10 years ago, the court may not give you a name change. American LegalNet, Inc. www.FormsWorkFlow.com Enter the Case Number given by the Circuit Clerk: NCM - CI 2004.2 Page 2 of 2 In 4, select all the reasons it is in the child's best interest to change their name. Use 223Other224 to add other reasons. 4. It is in the best interest of the child that their name be changed because ( check all that apply ) : I wish to have the child222s name changed. The child wishes to have their name changed. Other: 5 . I am providing the following information about other parents (do not include yourself or In 5, if there is another parent, list their name and address. If not, check "None . " parents whose rights as parents have been terminated by a court order) . None Name and address of other parent: First Middle Last Street , Apt # City State ZIP In 6, if the parent listed above agrees to this name change, have them sign their name in front of an Illinois notary public if they are not going to be at the court date. 6. The other parent listed above agrees to this name change. I don 222 t know No Yes ( If yes, have the other parent sign below) I, First Middle Last consent to the child222s name change. Signature (sign in front of an official Illinois notary public) Notary Public DO NOT complete this section. The notary will complete it. State of Illinois County of Signed and sworn to before me on by . D ate N ame Seal Signature of Notary In 7a or 7b, if there is a second parent or a person who is not the parent with physical custody of the child, check "Yes" and fill out and attach the Request for Name Change - Additional Parent form. If not, check "No." 7. There is a second parent or person who is not the parent with physical custody of the child. a. T here is a second parent. Yes (If yes, fill out and attach the Request for Name Change - Additional Parent form.) No b. There is a person who is not the parent with physical custody of the child. Yes (If yes, fill out and attach the Request for Name Change - Additional Parent form.) No American LegalNet, Inc. www.FormsWorkFlow.com