JV-124 (Rev. 11/05/2018) Page 1 of 2 PETITION FOR CHANGE OF NAME DOCKET NUMBER Trial Court of Massachusetts Juvenile Court Department DIVISION 1. Name of Petitioner: 2. The child's current legal name (if different from petitioner) is: 3. Child's date of birth: Child's SSN: Child's place of birth: Child's Address: 4. What is your relationship to the child? 5. Child's Parents: Mother Father Name: Address: Telephone:6. Reason for name change: 7. Has the child ever changed his/her name prior to this petition? Yes No If yes, please explain: (Attach a copy of the Name Change Judgment or Decree)8. A copy of the child's birth certificate is attached. WHEREFORE, the Petitioner requests that the child's name be changed as follows: Name at present: To be changed to: Petitioner requests the Court to waive public notice of this petition. As reasons the petitioner states: Mother assents to the petition to change the child's name. (See page 2) Father assents to the petition to change the child's name. (See page 2) Date: (Signature of Petitioner)(Address) Telephone No. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2JV-124 (Rev. 11/05/2018) I, , mother of the minor child hereby assent to the granting of the petition to change the child's name to . Date: Signature I, , father of the minor child hereby assent to the granting of the petition to change the child's name to . Then personally appeared before me the above named and affirmed under penalties of perjury that the foregoing is her free act and deed this day of , 20 . Notary Public: My Commission Expires:Date: Signature Then personally appeared before me the above named and affirmed under penalties of perjury that the foregoing is his free act and deed this day of , 20 . Notary Public: My Commission Expires:PARENTAL ASSENT American LegalNet, Inc. www.FormsWorkFlow.com