Pc122 SUPERIORCOURT Unit Unit STATEOFVERMONT PROBATEDIVISION DocketNo.____________ Inre____________________________________________of_______________________________ PETITONOFADULTTOCHANGENAME The undersigned petitioner represents as follows: That I was born at ________________________ on _______________; town/city and state date of birth That I have the following minor children, who were born in the following locations: Name of child town/city and state date of birth ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ That I am married to __________________________________ of ______________________________ That the name I wish to be known by is: ___________________________________________________ That I understand that by filing this petition I consent to the court's requesting the Department of Public Safety to determine whether the petitioner's name appears on the sex offender registry established by 13 V.S.A. § 5402 and to disclosure of the information to the court by the department; and I understand that, if the department reports that the petitioner's name appears on the registry, the court shall permit the department to appear o the question whether there is a compelling reason for granting the petition. Date: __________________ Signed: _____________________________________,Petitioner Print Name: _________________________________ Mailing Address: _____________________________ ___________________________________________ Telephone/email:_____________________________ At __________________________ on this ______ day of ___________________, 20____, _________________________________________ personally appeared before me and acknowledged this instrument by him/her signed, to be his/her free act and deed. ____________________________________________ Judge/Register 10/11 SML American LegalNet, Inc. www.FormsWorkFlow.com