Identity Record Change - Petition Page 1 of 1 (Nov 2017) IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF In the Matter of: Case No: PETITION FOR CHANGE OF NAME SEX Petitioner (current name) Adult I am the Petitioner. I am at least 18 years old or I have been emancipated by court order. I ask the court for a judgment changing my (check all that apply): name (use complete names. First, Middle, Last) from: to: sex to: male female nonbinary I have undergone surgical, hormonal, or other treatment appropriate to me for the purpose of affirming my gender identity I ask that this record be SEALED by the court because: (check all that apply) I am a participant in the Address Confidentiality Program under ORS 192.826 I am requesting a change of sex and I want the record to be sealed Certificate of Document Preparation. Check all that apply: I chose this form for myself and completed it without paid help A legal help organization helped me choose or complete this form, but I did not pay money to anyone I paid (or will pay) for help choosing, completing, or reviewing this form Guide & File selected and completed this form and I did not pay anyone to review the completed form I hereby declare that the above statements are true to the best of my knowledge and belief. I understand they are made for use as evidence in court and I am subject to penalty for perjury. Date Signature Name (printed) (current name) Contact Address City, State, ZIP Contact Phone American LegalNet, Inc. www.FormsWorkFlow.com