IN CIRCUIT COURT ) )ss: COUNTY OF ______________________ ) ___________ JUDICIAL CIRCUIT ) ******************************************************************************* In the Matter of the Petition of ) ) _________________________________ ) CIV: _______________ (Current Name) ) ) For a Change of Name to ) ORDER FOR ADULT NAME CHANGE ) ___________________________________ ) (Proposed Name) ) ) ******************************************************************************* STATE OF SOUTH DAKOTA The above-entitled matter having come before this Court, on this ________ day of ___________________, 20___; the Petitioner __________________________________________, appearing personally and no one appearing in opposition to said Verified Petition for Adult Name Change; now, upon the testimony, evidence and entire record, it is, by the Court FOUND AND DETERMINED that the Court has full and complete jurisdiction of the subject matter hereof pursuant to SDCL chapter 21-37, SDCL 34-25-51, and ARSD 44:09:05:02; and it is further FOUND AND DETERMINED that at the time of filing the Verified Petition for Adult Name Change herein, the Petitioner is a resident of _____________________________ County, South Dakota and has been a bona fide resident of ___________________________ County, South Dakota for more than six months prior to the filing of the petition; and it is further FOUND AND DETERMINED that notice of the proposed name change was given by publication of the same once each week for four successive weeks as required by SDCL § 21-37-4 as shown by the Affidavit of Publication of ________________________________ (name of legal county newspaper) on file herein; and it is further Form UJS-027 Order for Adult Name Change Rev. 06/2011 American LegalNet, Inc. www.FormsWorkFlow.com FOUND AND DETERMINED that: 1. Petitioner's full name on petitioner's birth certificate is _________________________ ______________________________________________________________________; 2. Petitioner's date of birth is ________________________________________________; 3. Petitioner was born in the State of _________________________________, County of _______________________________, and city or town of ______________________; 4. Petitioner's mother's full maiden name as it appears on petitioner's birth certificate is ______________________________________________________________________; 5. Petitioner's father's full name as it appears on petitioner's birth certificate is _________ ______________________________________________________________________; and it is further FOUND AND DETERMINED that the name of the petitioner, as it appears on petitioner's birth certificate, __________________________________________________________________, shall be changed to _______________________________________________________________; and it is further FOUND AND DETERMINED that the allegations set forth in the Verified Petition for Adult Name Change are true and there is reasonable and proper cause for changing the name of the petitioner; NOW, THEREFORE, IT IS ORDERED, ADJUDGED AND DECREED, that the name of the petitioner, as it appears on petitioner's birth certificate, ______________________________________________________ shall be changed to ________________________________________________________________ and this Order shall be entered by the clerk; and it is further Form UJS-027 Order for Adult Name Change Rev. 06/2011 American LegalNet, Inc. www.FormsWorkFlow.com ORDERED, ADJUDGED AND DECREED, that should petitioner choose to change petitioner's birth certificate, the petitioner must provide the Department of Health Office of Vital Records in the state where the petitioner was born with a certified copy this "Order for Adult Name Change" and pay Department of Health Office of Vital Records the applicable filing fee for amending the birth certificate; that the Department of Health, Office of Vital Records in the state where the petitioner was born shall locate the petitioner's birth certificate using the identifying information above, verify that information within the state's vital records registration system, and, within a reasonable time after receiving both the certified copy of this "Order for Adult Name Change" and the applicable fee from petitioner, amend the petitioner's birth certificate by changing the petitioner's name of ____________________________________________________, currently on the birth certificate, to the name of ________________________________________________. Dated this ____ day of __________________________, 20_______. By The Court _____________________________________ Circuit Court Judge ATTEST: _______________________________ Clerk of Courts By: ____________________________ Deputy Form UJS-027 Order for Adult Name Change Rev. 06/2011 American LegalNet, Inc. www.FormsWorkFlow.com