IN THE COURT OF COMMON PLEAS OF ____________________ COUNTY, PENNSYLVANIA CIVIL DIVISION INSTRUCTIONS TO THE PETITIONER: Under the Immigration and Nationality Act of 1952, as amended by the Immigration Act of 1990 (section 336), an applicant who chooses to have the oath of allegiance administered by a State Court also can change his or her name by decree of that court. The decree of name change will be issued at the same time as the administration of the oath of allegiance, and the certificate of naturalization shall be issued in accordance therewith. If you elect the State Court ceremony, and wish to change your name, please clearly print or type the information requested. I hereby petition this Court to change my name. In support of my petition, subject to the penalties of 18 Pa. C.S.A. § 4904 (Unsworn falsification to authorities), I truthfully state the following: My full, correct, current name is ______________________________________________________________________________ My present address is ______________________________________________________________________________ I have resided at this address since ______________________________________________________________________________ My country of birth is ______________________________________________________________________________ Birthdate _____________________ My Alien Registration No. is A______________ I wish to change my name to ______________________________________________________________________________ Subject to the penalties of 18 Pa. C.S.A. § 4904 (Unsworn falsification to authorities), I certify that I have never been convicted of a felony or misdemeanor and that there are no civil judgments for money presently outstanding against me. Date: _______________________ ______________________________________ (Signature of Petitioner or of Petitioner's Parent) ***** ORDER OF COURT AND NOW, this ___________ day of ________________________________, __________, pursuant to 8 U.S.C. § 1447(e), it is hereby ORDERED that the above Petitioner's name be and the same is hereby changed to: _______________________________________________________________________. BY THE COURT: _________________________________________ Judge W-1F-1 (Rev. 4/00) American LegalNet, Inc. www.FormsWorkflow.com