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 FOR ADULT MINOR 1. Petitioner Name Mailing Address Petitioner Name Mailing Address 2. Minor Name Mailing Address Relationship of petitioner to minor 3. Attorney Name Mailing Address 4. Telephone Bar ID# Telephone Telephone Telephone Are there any pending guardianship, juvenile, domestic violence, marriage dissolution, domestic relations, paternity, legitimization, custody or other proceedings affecting this child or the Yes No If yes, attach a separate sheet proposed adoptive parents of this child? identifying and explaining each. Please complete the following information as it applies to the person whose name is being changed. 5. 6. 7. Town of residence Date of birth If minor, name of mother Mailing Address Place of birth 8. If minor, name of father Mailing Address NHJB-2175-P (03/25/2013) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Name change of Case Number: PETITION FOR CHANGE OF NAME 9. 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. I certify that I have had the sheriff's department serve a copy of this petition on the department of corrections. I understand that failure to comply with notification requirements shall cause any order 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. I certify that I have had the sheriff's department serve a copy of this petition on the department of safety or other agency. I understand that failure to comply with notification requirements shall cause any order hereunder to be null and void. Neither of the above paragraphs are applicable to this name change. The petitioner requests that the name (First, middle and last names) be changed in accordance with the laws of the State of to (First, middle and last names) New Hampshire and for the following reasons: Except as noted in #9 above, I certify that on this date I provided this document(s) to the parties who have filed an appearance for this case or who are otherwise interested parties by: Hand-delivery OR US Mail OR Email (E-mail only by prior agreement of the parties based on Circuit Court Administrative Order). Date Date Petitioner Signature Petitioner Signature PLEASE NOTE: If this name change is for a minor, a certified copy of the minor's birth certificate must accompany this petition. If this name change is for an adult, proof of identity must accompany this petition. ORDER The above petitioner has sworn before the judge that the facts are true to his/her best knowledge and belief. Accordingly, the court orders that: Petition is granted. Petition is denied. Date Judge American LegalNet, Inc. www.FormsWorkFlow.com NHJB-2175-P (03/25/2013) Page 2 of 2