YAKIMA COUNTY DISTRICT COURT In the Matter of the Change of Name of: _____________________________________, [Print legibly or type your full name here] Petitioner NO.:_________________________________ PETITION FOR CHANGE OF NAME [ADULT] 1. I am Petitioning for a court order that will change my name from: First: to First: 2. My birth date is: 3. My father's name is : 4. My mother's name is: 5. I reside in Yakima County, Washington. Middle: Middle: Last: Last: 6. This application is made for the following reason(s): 7. I am not making this Petition for any illegal or fraudulent purposes or to defraud any creditors. The change of name would not be detrimental to the interest of any other person. PETITION NAME CHANGE ­ ADULT 5/2004 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 8. I am not subject to the jurisdiction of the Washington Department of Corrections. I am subject to the jurisdiction of the Washington State Department of Corrections. I certify that I provided a copy of this Petition to the Department on .I know I must provide a copy of any order granting a name change to the Department within five days of its entry by the Court and that failure to do so is a crime. 9. I am not subject to the sex offender registration laws of the State of Washington. I am subject to the sex offender registration laws of the State of Washington. I certify that I provided a copy of this Petition to the Yakima County Department on and the Washington State Patrol on . I know I must provide a copy of any order granting a name change to the sheriff of the County where I reside and to the Washington State Patrol within five days of its entry by the Court and that failure to do so is a crime. 10. I declare under penalty of perjury under the laws of the State of Washington that the foregoing statements are true and correct. Signed at [Write in city where you signed this form] on [Write in date you signed this form] [Sign your name here] PETITION NAME CHANGE ­ ADULT 5/2004 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com