VIRGINIA: IN THE VIRGINIA BEACH CIRCUIT COURT - APPLICATION FOR ADULT NAME CHANGE-VA. CODE 247 8.01-217 NAME OF APPLICANT: CASE No. (Supplied by Clerk): CL The above-named applicant states under oath that the information contained in this application and in any attachments to this document are both correct and accurate. 1. My birth name is: 2. My current name is: 3. I am applying to change my name to: 4. My Residence Address is: 5. My Date of Birth is: 6. My Place of Birth is: 7. My Father222s Full Name: 8. My Mother222s Current Full Name: 9. Mother222s Maiden Name: 10. Have you ever been convicted of felony? . 11. Are you required to register with the Sex Offender and Crimes Against Minors Registry? . If yes, (i) attached is a statement under oath stating the reasons for the name change and (ii) the name(s) of the jurisdiction(s) where the conviction(s) occurred that resulted in my registration is/are: 12. Are you currently incarcerated? . If yes, (i) attached is a statement under oath stating the reasons for the name change, (ii) the name(s) of the jurisdiction(s) where the conviction(s) occurred that resulted in my current incarceration is/are: and (iii) the facility222s name where I am incarcerated is: 13. Are you a presently a probationer with any court? . If yes, (i) attached is a statement under oath stating the reasons for the name change and (ii) the name of the jurisdiction(s) where the conviction(s) occurred that resulted in my probation is/are: 14. Have you previously changed your name? . If yes, attach court order or documentation of the previous name change(s) and list all former name(s) in a 223from and to224 format: American LegalNet, Inc. www.FormsWorkFlow.com 15. This name change is not sought for any fraudulent purposes and will not infringe upon the rights of others. 16. A copy of one of the following 223unexpired224 documents establishing the identity of the applicant is attached to this application: a state-issued driver's license or state-issued identification card, a United States military card, a United States Passport, a certificate of United States citizenship, a certificate of naturalization, an alien registration card with photograph, or a foreign passport. Code 247 47.1-2. Signature of Applicant (Current Legal Name) AFFIDAVIT Subscribed and sworn to/affirmed before me. DATE: DEPUTY CLERK OR Commonwealth/State of: ; City/County of: Subscribed and sworn to/affirmed before me in accordance with the provisions of Virginia Code 247 47.1-14. DATE: Signature of Notary My commission expires: Printed Name of Notary: Revised May 10, 2017 American LegalNet, Inc. www.FormsWorkFlow.com