KSJC 8/2012 IN THE JUDICIAL DISTRICT DISTRICT COURT OF COUNTY, KANSAS Case No. AFFIDAVIT REQUESTING ORDER RESTORING NAME moves the Court to restore: My maiden name of . My previous married name of . VERIFICATION I verify under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct. Executed on , 20. Signature Name Print): Address (1): Address (2): City, ST, Zip: Telephone: Authority: K.S.A. 23-2716.IN THE MATTER OF THE MARRIAGE OF , Petitioner, and , Respondent. American LegalNet, Inc. www.FormsWorkFlow.com KSJC 8/2012 IN THE JUDICIAL DISTRICT DISTRICT COURT OF COUNTY, KANSAS Case No. ORDER ON the day of , 20 , the Court considers the application of the Petitioner Respondent for restoration of maiden previous married name. Having reviewed the affidavit, the Court orders that the Petitioner222s Respondent222s name be restored to . IT IS SO ORDERED. Judge Authority: K.S.A. 23-2716. IN THE MATTER OF THE MARRIAGE OF , Petitioner, and , Respondent. American LegalNet, Inc. www.FormsWorkFlow.com