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 seeking a change of name pursuant to Virginia Code §8.01-217 and respectfully states under oath as follows: The petitioner currently resides in the County/City of . The petitioner desires 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 petitioner is . The current address of the petitioner, including street, city and state of residence is . The petitioner's father is is , whose maiden name is The petitioner's date of birth is of the petitioner is and the petitioner's mother . , and the place of birth . The petitioner has a felony conviction record, or is currently incarcerated or a probationer with any court, as follows: . The petitioner has never previously had a change of name. Signature of Petitioner Daytime Phone Number 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 is signed to the foregoing Petition, and acknowledged day of , . the same under oath before me. Given under my hand and seal this Deputy Clerk/Notary Public CCR A-160 9-10 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, seeking to change name. IT APPEARING to the Court that: The current address of the petitioner, including street, city and state of residence is _______________________________________________________________________. The petitioner has never previously had a change of name. ADJUDGED, ORDERED and DECREED that the name of the petitioner 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(s) of Petitioner(s) CCR A-160 9-10 October 2006 American LegalNet, Inc. www.FormsWorkflow.com