IN THE COURT OF COMMON PLEAS OF MONTGOMERY COUNTY, PENNSYLVANIA ________________________________ ________________________________ : : VS. ________________________________ ________________________________ : : : NO. NOTICE TO RETAKE PRIOR SURNAME Notice is given that the Plaintiff/Defendant, being party to an action in divorce filed on Montgomery County on the ______ day of______, 20___ , elects to retake and use her prior surname. ___________________________________ Signature (married name) ___________________________________ Print (married name) TO BE KNOWN AS: ___________________________________ Signature (prior surname) ___________________________________ Print (prior surname) ADDRESS: ___________________________________ Street Address ___________________________________ City, State, Zip Code (12/10) American LegalNet, Inc. www.FormsWorkFlow.com