IN THE CHANCERY COURT OF TENNESSEE FOR THE THIRTIETH JUDICIAL DISTRICT AT MEMPHIS IN THE MATTER OF: DOCKET NO: CH- PETITIONER PETITION FOR ADULT CHANGE OF NAME TO THE HONORABLE CHANCELLORS OF THE CHANCERY COURT OF SHELBY COUNTY, TENNESSEE: Comes now the Petitioner , in the above captioned cause, and files this petition requesting a change of name and for cause of action would show unto the Court the following: 1. Petitioner is an adult resident, citizen of Shelby County, Tennessee. 2. Petitioner would further show unto the Court that he/she was born in County, of the state of on and my name appears as on my birth certificate. 3. Petitioner desires to change his/her name for the following reasons . 4. Petitioner respectfully requests of this Honorable Court that he/she be allowed to change his/her name to . American LegalNet, Inc. www.FormsWorkFlow.com 5.Petitioner further states that he/she is not a felon or criminal and that the reasons for thename change are personal and that he/she does not seek such name change to avoid or evadeany debts or obligations. Nor is this name change requested for any illegal purpose. WHEREFORE, PREMISES CONSIDERED, YOUR PETITIONER PRAYS: 1. That upon the hearing of this cause, the court order the legal change of the name of thepetitioner to . 2. For all other relief, both general and special, to which he/she may be entitled in thepremises. PETITIONER STATE OF TENNESSEE COUNTY OF SHELBY I, , being first duly sworn according to law, state that the contents herein are true to the best of my knowledge, information and belief. PETITIONER Sworn to and subscribed before me this day of , . Donna L. Russell, Clerk & Master By Deputy Clerk Revised 06/04/2018 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF TENNESSEE COUNTY OF SHELBY AFFIDAVIT FOR NAME CHANGE The undersigned, having petitioned for a name change, hereby makes oath, as required by T.C. A. 247 29-8-101 (b) that: 1.I have never been convicted of First or Second Degree Murder. 2.I have never been convicted of any offense, the commission of which requiresregistration pursuant to the 223Sexual Offender Registration and Monitoring Act224found in Tennessee Code Annotated, Title 40, Chapter 39. Name Address City, State, Zip Code Phone Number Sworn to and subscribed before me this day of , 20 . Donna L. Russell, Clerk & Master Deputy Clerk Revised 6/04/2018 American LegalNet, Inc. www.FormsWorkFlow.com IN THE CHANCERY COURT OF TENNESSEE FOR THE THIRTIETH JUDICIAL DISTRICT AT MEMPHIS IN THE MATTER OF: DOCKET NO: CH- PETITIONER ORDER ALLOWING NAME CHANGE This cause came to be heard on this date upon the sworn petition of upon the respective testimony in open court, and upon the entire record in this cause. It appearing to the Court from all of the above that was born in on , and is presently a resident of Shelby County, Tennessee and that petitioner for good and sufficient cause desires to change his/her name to and that the change should be officially noted on the petitioner222s birth certificate, and old information blocked and deleted. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the name of be and hereby changed to and that such name change be officially shown and designated hereafter for all legal purposes as such and that a copy of this Order be furnished to appropriate State and County agencies to effectuate the purpose of this Order for Name Change. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the appropriate State and County agencies officially note on the Petitioner222s birth certificate the ordered changes and the old information be blocked and deleted. American LegalNet, Inc. www.FormsWorkFlow.com PETITIONER ADDRESS CITY, STATE & ZIP CODE TELEPHONE NUMBER CHANCELLOR DATE Revised 06/04/2018 American LegalNet, Inc. www.FormsWorkFlow.com HOW TO OBTAIN NEW IDENTIFICATION TO GET A NEW BIRTH CERTIFICATE: Contact the Department of Health in the State where you were born.If you were born in Tennessee-A certified copy of the court order; original birth certificate and a check or money order for$27.00 should be sent to: TN Vital Records, 710 James Robertson Parkway, Nashville, TN37243It usually takes 3-4 weeks to receive your new birth certificate.If you wish to speak with someone, call (615) 741-1763 Amendment Unit. TO GET A NEW SOCIAL SECURITY CARD: Go to any local Social Security officeCall (800) 772-1213 to request an application, you should receive it in the mail within 2 weeks.The web address is www.socialsecurity.gov. There is no charge for a new social security card. TO GET A NEW DRIVERS LECENSE: Take a certified copy of the court order to the testing center located at 6340 Summer AvenueThe hours of operation are Monday-Friday 8:30am 226 5:00 p.m.There is a $12.50 charge.If you wish to speak directly with someone, call 543-7920.The web address is www.state.tn.us/safety. American LegalNet, Inc. www.FormsWorkFlow.com