IN THE DISTRICT COURT OF THE STATE OF WASHINGTON IN AND FOR THE COUNTY OF SPOKANE In the Matter of the Petition of NO. ___________________ _________________________________________________ Petitioner (Current Full Legal Name) Date of Birth ______________ Age ________ PETITION FOR CHANGE OF NAME (RCW 4.24.130) 1. I am applying for a Court Order which will change my name: A. FROM: (Current Full Legal Name) Current First Name Current Middle Name Current Last Name B. TO: (New Legal Name Desired) Proposed First Name Proposed Middle Name Proposed Last Name 2. This "Petition for Change of Name" is made for the following reason(s): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. I reside in Spokane County? Yes No 4. My physical (residential) address: ______________________________________________ ______________________________________________ Phone Number: ______________________________________________ ______________________________________________________________________________ Petition for Change of Name (rev 7/16) PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com 5. Does any person (entity) have guardianship over your person or estate? Yes No 6. Do you have picture identification to show and be copied by the Clerk? Yes No 7. Is this Petition being made to avoid creditors? Yes No 8. Is this Petition being made for any illegal or fraudulent purpose? Yes No 9. Is this Petition being made because of domestic violence and you desire to have the name changed sealed due to reasonable fear for safety (RCW 4.24.130 (5))? Yes No 10. I AM under the jurisdiction of the Department of Corrections (or under probation with the Department of Corrections)? * Yes No 11. I AM required to register as sex offender under RCW 9A.44.130?** Yes No 12. Is there anything else you would like to present to the Court in support of your name change? Please describe. _______________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ *** I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing statements in this petition are true and correct. Signed at Spokane County, Washington on this the _____ day of _____________, 2016. ____________________________________________ Petitioner's Signature ____________________________________________ Print Petitioner's Name * If under the jurisdiction of Department of Corrections, a copy of this application (petition) shall be submitted (BY THE PETITIONER) to said Department not fewer than five (5) days before entry of an order granting name change (AND HAVE PROOF OF SAME), and offender shall submit a copy of the order to said Department within five (5) days of entry of an order granting name change. Violation of a misdemeanor. RCW 4.24.130(2). ** If subject to registration under RCW 9A.44.130 (sex offender statute) a copy of this application (petition) shall be submitted (BY THE PETITIONER) to the Spokane County Sheriff AND the Washington State Patrol not fewer than five (5) days before entry of an order granting name change (AND HAVE PROOF OF SAME), and offender shall submit a copy of the order to said Sheriff and the WSP within three (3) business days of entry of an order granting name change. See RCW 9.44.130(7). District Court complies with Americans with Disability Act ­ for accommodations contact Court Operations Manager 477-2903 ______________________________________________________________________________ Petition for Change of Name (rev 7/16) PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com