STATE OF MAINE DISTRICT COURT Location Docket No. In re: (Name of Minor) PETITION FOR CHANGE OF NAME (MINOR) 18-A M.R.S. � 1-701 1. Name of Petitioner: ______________________________________________________ 2. Address and telephone number of Petitioner. (Include physical address, if different): ______________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 3. Date of birth of minor: ____________________________________________________ 4. The following certified and valid documents are to be provided to the court: Birth certificate of minor Divorce Judgment, and any modifications, if any Court order pertaining to custody of the child, and any modifications, if any Death certificate of deceased custodian, if any 5. Full legal name of minor (include middle name, if any): _________________________ _________________________________________________________________________ 6. The minor currently resides at the following address: ____________________________ _________________________________________________________________________ 7. Petitioner wishes to change the minor's name to (include middle name, if any): _______ _________________________________________________________________________ PB-004, Rev. 07/16 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 8. Petitioner wishes to change the minor's name for the following reasons: ____________ _________________________________________________________________________ _________________________________________________________________________ Dated: __________ ___________________________________________ Signature of Petitioner � Relationship to Child Dated: __________ ___________________________________________ Signature of Co-Petitioner � Relationship to Child ___________________________________________ If Petitioner is represented by an attorney, said attorney must also sign petition pursuant to M.R. Civ. P. 11. Dated: __________ PB-004, Rev. 07/16 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com