V I R G I N I A IN THE CIRCUIT COURT OF FAIRFAX COUNTY IN RE: CHANGE OF NAME FOR MINOR CHILD : AT LAW # _____________________________ FROM: TO: (CURRENT LEGAL NAME OF CHILD) (N EW NAME REQUESTING) AFFIDAVIT FOR SERVICE BY PUBLICATION Comes now , Petitioner herein, seeking service on , the natural parent by ORDER OF PUBL ICATION, and who under oath deposes and states under oath that the Natural Parent in this cause, Is a non-resident individual, other than a non-resident individual fiduciary who has appointed a statutory agent; OR Cannot be found, and that diligence has been used without effect to ascertain the location of the party to be served; OR Cannot be served with court process, and that a return has been filed by the Sheriff which shows that the process has been in his or her hands for twenty-one (21) days and the Sheriff has been unable to make service; OR OTHER: ______________________________________________________________________________________ and last known mailing address of Natural Father/Mother is as follows: NAME: _________________________________________ ADDRESS: _________________________________________ _________________________________________ OTHER INFORM ATION: ______________________________________________________________________________ Explanation of circumstances: ___________________________________________________________________________ ___________________________________________________ Signature of Petitioner ___________________________________________________ Counsel of Petitioner TO BE COMPLETED BY A NOTAR Y PUBLIC/OR DEPUTY CLERK In the Commonwealth/State of: In the County of : Subscribed and sworn to before me by this day of , . My Commission Expires: _____________________ Notary Public/Deputy Clerk CCR A-180 July 12 2004 American LegalNet, Inc. www.USCourtForms.com>>>> 2 V I R G I N I A: IN THE CIRCUIT COURT OF FAIRFAX COUNTY IN RE: CHANGE OF NAME FOR MINOR CHIL D : AT LAW# ______________________________ FROM: TO: __________________________________ (CURRENT LEGAL NAME OF CHILD) (NEW NAME REQUESTING) ORDER OF PUBLICATION The reason for this cause is to obtain name change for minor child An affidavit having been made and filed showing that the Natural Parent in the above-entitled cause is Is a non-resident individual, other than a non-resident individual fiduciary who has appointed a statutory agent; OR Cannot be found, and that diligence has been used without effect to ascertain the location of the party to be served; OR Cannot be served with court process, and that a return has been filed by the Sheriff which shows that the process has been in his or her hands for twenty-one (21) days and the Sheriff has been unable to make service; OR OTHER: and last known mailing address of Natural Father/Mother is as follows: Name :_____________________________________________ Address: __________________________________________ __________________________________________ TO BE COMPLETED BY CLERKS OFFICE Upon consideration, this Order of Publication is granted, and it is ORDERED that the above named Natural Parent shall appear here on or before day of , after proper publication of this Order, to protect his/her interest in this cause. ENTERED: TESTE: JOHN T. FR EY, CLERK BY: ___________________________________ DEPUTY CLERK ________________________________________ Signature of Petitioner or Counsel for Petitioner Address: ________________________________ ________________________________________ Phone Number: ___________________________ CCR A-180 July 12 2004 American LegalNet, Inc. www.USCourtForms.com