VIRGINIA FAIRFAX CIRCUIT COURT In the matter of the change of name of Civil No. ______________ to PETITION FOR CHANGE OF NAME COMES NOW the petitioner(s) seeking a change of name for Virginia Code §8.01-217 and respectfully states under oath as follows: child/ward pursuant to The child/ward currently resides in the County/City of . The petitioner(s) desire a change of name for the following reasons: . This change of name is not sought for any fraudulent purpose and will not infringe on the rights of another. The name of the child/ward is . The current address of the child/ward, including street, city and state of residence is . The child/ward's father is is and the child/ward's mother , whose maiden name is The child/ward's date of birth is of the child/ward is . , and the place of birth . The child/ward has a felony conviction record, or is currently incarcerated or a probationer with any court, as follows: . The child/ward has never had a change of name. Signature of Petitioner Daytime Phone No.____________ Signature of Petitioner Daytime Phone No.____________ *****If there are TWO petitioners, EACH Petitioner's Signature must be notarized.***** IN THE COMMONWEALTH OF VIRGINIA, COUNTY OF : I, the undersigned Deputy Clerk/Notary Public in and for the State of Virginia, do hereby certify that before me appeared , whose name(s) is/are signed to the foregoing Petition, and day of acknowledged the same under oath before me. Given under my hand and seal this . , Deputy Clerk/Notary Public CCR A-160 17-18 October 2006 My Commission expires: American LegalNet, Inc. www.FormsWorkflow.com VIRGINIA FAIRFAX CIRCUIT COURT In the matter of the change of name of Civil No. ____________ to ORDER This day came the petitioner(s), seeking to change the name of minor child/ward. IT APPEARING to the Court that: The current address of the child/ward, including street, city and state of residence is _____________________________________________________________________________. The child/ward has never previously had a change of name. ADJUDGED, ORDERED and DECREED that the name of the child/ward is hereby changed from to , and further ADJUDGED, ORDERED, and DECREED that the Clerk of this Court, pursuant to the provisions of Virginia Code §8.01-217 shall spread this order upon the current deed book, index it in both the old and new names, and transmit a certified copy to both the State Registrar of Vital Statistics and the Criminal Records Exchange. Entered this day of , . ____________________________________ JUDGE I ASK FOR THIS: ____ Signature of Petitioner CCR A-160 17-18 October 2006 Signature of Petitioner American LegalNet, Inc. www.FormsWorkflow.com