STATE OF SOUTH DAKOTA ) IN CIRCUIT COURT )ss: COUNTY OF __________________ ) ____________ JUDICIAL CIRCUIT ) ********************************************************************************* In the Matter of the Petition regarding ) ) ________________________________ ) CIV: _______________ (Birth Certificate Name), A Minor Child. ) ) For a Change of Name to ) CONSENT ) (UNCONTESTED NAME CHANGE) ________________________________ ) (Proposed Name) ) ) ********************************************************************************* STATE OF SOUTH DAKOTA COUNTY OF _______________ ) ) ) I, ____________________________, being first duly sworn, state as follows: (Consenting Parent) 1. I am the [ ] mother [ ] father of ____________________________________, which is the minor child's name, as it appears on the child's birth certificate, who was born on _______________________ in ___________________, ____________________ County, State of ________________. 2. I hereby freely and voluntarily and not as a result of any threat or premise, consent to the name change of my minor child ________________________________________ __________________________________________________________________ to ____________________________________________________________________. 3. The reason why I consent to the above name change of my minor child is: _________ _____________________________________________________________________ _____________________________________________________________________ ____________________________________________________________________. Page 1 of 2 UJS-033 Consent Rev. 06/2011 American LegalNet, Inc. www.FormsWorkFlow.com Dated this _____ day of _________________, 20____. ______________________________ Signature of consenting parent ______________________________ Printed name of consenting parent ______________________________ Street address of consenting parent ______________________________ City, State, ZIP code of consenting parent ____________________________________ Telephone number of consenting parent STATE OF SOUTH DAKOTA COUNTY OF ______________ ) )SS ) On this the _________ day of, ____________________, 20_____, before me, the undersigned officer, personally appeared ,___________________________, known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument entitled Consent and acknowledged that he/she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. ______________________________ Notary Public My Commission Expires: ____________________ (SEAL) Page 2 of 2 UJS-033 Consent Rev. 06/2011 American LegalNet, Inc. www.FormsWorkFlow.com