IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE THIRD JUDICIAL DISTRICT In the Matter of the Change of Name of: ) ) _______________________________________________ ) (Present Full Name) Petitioner ) ) to:_____________________________________________ ) (Proposed New Name) ) 1. Case No: _____________ PETITION FOR CHANGE OF NAME I, _________________________________________petitioner, request a judgment changing my name as set forth in the title of this petition. 2. 3. 4. I am age 18 or older and I reside in Marion County. My date of birth is: ___________________ I am requesting this name change because: _____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury. _______________________________ Petitioner Subscribed and Sworn to before me this _____ day of _____________, 20_____. _______________________________________________ Clerk/Notary/Judge My commission expires:__________ Submitted by: _____________________________________________________________________________ Attorney/Petitioner's Name Address _____________________________________________________________________________ City State Zip Phone No. If Attorney: Bar No. E-mail Fax Certificate of Document Preparation If this document was not completed by an attorney, I hereby certify that the following statements are true: (check all boxes and complete all blanks that apply) A. G I selected this document for myself, and I completed it without paid assistance. B. G I paid or will pay money to _________________ for assistance in preparing this form/document __________________________ Signature PETITION FOR CHANGE OF NAME ­ Page 1 of 1 FC (2/23/12)(Form 1)