THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Name change of PETITION FOR CHANGE OF NAME related to FAMILY DIVISION JURISDICTION for ADULT MINOR (pursuant to RSA 490-D:2, X) 1. The petitioner is filing this name change request with the Family Division because the request relates to the following type of case (check all that apply): Divorce Annulment Guardianship Adoption List Court Name(s) Case Name(s) Case Number(s) related case(s). Parenting Petition Petition for Support Abuse and Neglect Termination of Parental Rights Petition for Paternity Domestic Violence Petition Delinquency/CHINS , and of the Note: If the name change request DOES NOT relate to one of the case types above, the petitioner should file for a name change with the Probate Division. 2. The petitioner requests that the name (First, middle and last names) be changed to (First, middle and last names) in accordance with the laws of the State of New Hampshire and for the following reasons: 3. Petitioner Name Mailing Address Telephone 4. Minor Name (if applicable) Mailing Address Relationship of petitioner to minor Telephone NHJB-2319-F (07/01/2011) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Name change of Case Number: PETITION FOR CHANGE OF NAME 5. Attorney Name (if applicable) Mailing Address Telephone PLEASE COMPLETE THE FOLLOWING INFORMATION AS IT APPLIES TO THE PERSON WHOSE NAME IS BEING CHANGED. 6. 7. 8. Town of residence Date of birth If minor, name of mother Mailing Address 9. If minor, name of father Mailing Address 10. If minor, name of guardian(s), if any Mailing Address 11. Check the following paragraphs that apply to the person whose name is being changed. I am a person who is serving a prison sentence, or who is on probation or parole, and I certify that I have sent a copy of this petition to the department of corrections as required by law. I understand that failure to comply with notification requirements shall cause any decree hereunder to be null and void. I am a person who is required to register as a sexual offender or an offender against children pursuant to RSA 651-B, and I certify that I have sent a copy of this petition to the department of safety or other agency as required by law. I understand that failure to comply with notification requirements shall cause any decree hereunder to be null and void. Neither of the above paragraphs is applicable to this name change. 12. I authorize the court to conduct a criminal record check on my current name and any previous names I have used, or to conduct a criminal record check on any names used by the person whose name I am seeking to change, by submitting the attached Criminal Record Release Authorization Form. Place of birth Date Petitioner Signature State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any , County of by Signature of Notarial Officer / Title NHJB-2319-F (07/01/2011) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Name change of Case Number: PETITION FOR CHANGE OF NAME ORDER The above petitioner has sworn before the judge/master that the facts are true to his/her best knowledge and belief. Accordingly, the court orders that: Petition is granted. Petition is denied. Recommended: Date Signature of Marital Master Printed Name of Marital Master So Ordered: I hereby certify that I have read the recommendation(s) and agree that, to the extent the marital master/judicial referee/hearing officer has made factual findings, she/he has applied the correct legal standard to the facts determined by the marital master/judicial referee/hearing officer. Date Signature of Judge Printed Name of Judge NHJB-2319-F (07/01/2011) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com