IN THE DISTRICT COURT OF JUDICIAL DISTRICT COUNTY, KANSAS IN THE MATTER OF THE PETITION OF Case No. _____________ Present Name Div. No. ______________ To Change His/Her Name to: New Name PURSUANT TO K.S.A. CHAPTER 60 PETITION FOR CHANGE OF NAME Pursuant to K.S.A. 60-1402 Petitioner states: 1. I reside in the County in which this Petition is being filed. 2. I have been a resident of Kansas for more than sixty (60) days before filing this petition. 3. My YEAR of birth is and my place of birth is _________________________ County in the State of ______________________. 4. My birth certificate shows my name as:_____________________________________. 5. My present name is: ______________________________________________. 6. Other names I am using or have used are: ___________________________________ _____________________________________________________________________________. 7. I desire to have my name changed to:_______________________________________ because_______________________________________________________________________ _____________________________________________________________________________. KSJC 12/2010 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 8. This Petition is not made for the purpose of avoiding any debts, obligations or legal process nor is it made for the purpose of misleading or defrauding any person. The requested name change will not result in prejudice to any person. 9. My best interests are served by the requested change in name. I ask the Court to set this matter for hearing and order service by publication, registered mail or certified mail, or, if appropriate, waive any requirement for service. I further ask the Court to issue an order changing my name from ______________________________________ to ____________________________________ and for such other relief as the Court deems appropriate under the circumstances. I affirm under penalty of perjury that all statements in this Petition for Change of Name are accurate to best of my knowledge. _________________________________________ Petitioner, Pro Se Name (Print):______________________________ Address 1: ________________________________ Address 2: ________________________________ City, State, Zip: ____________________________ Telephone Number: _________________________ KSJC 12/2010 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com