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 previously had a change of name or changes of name, as follows: . 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 11-12 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 previously had a change of name or changes of name, as follows: . 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 11-12 October 2006 American LegalNet, Inc. www.FormsWorkflow.com