Free CCCO 0039 2-23-09.pmd - Illinois

Petition for Change of Name

(Page 1 of 3) IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS

(Rev. 2/23/09) CCCO 0039 A

IN THE MATTER OF THE PETITION OF

____________________________________________________________
FOR CHANGE OF NAME TO

____________________________________________________________
PETITION

}

No. _____________________________________

I/We, _______________________________________________________, request the entry of an order by this Honorable Court in compliance with the provisions of 735 ILCS 5/21-101 et. seq. for a change of name and in support of this petition and under penalties for perjury as provided by Section 1-109 of the Code of Civil Procedure (735 ILCS 5/1-109) state: A. FOR MYSELF 1. My date of Birth is: __________________________, __________. 2. My place of birth was: ____________________________________________. 3. My current residence address is:___________________________________________________________________________________. I have lived in Illinois since __________________________, __________. (Insert date.) 4. I will have published notice of my intention to apply to this court for a change of name. A copy of that notice will be filed with the Clerk of Court. 5. I 6. I 7. I 8. I am have have have am not required to register as a sex offender under the Sex Offender Registration Act (730 ILCS 150/1 et. seq.). have not been convicted of identity theft. have not been convicted of aggravated identity theft. have not been convicted or placed on probation for a felony or misdemeanor in the State of Illinois or any other state. (If you have

been convicted or placed on probation give details including name of offense, date of conviction or probation, sentence imposed and date of end of sentence including parole or mandatory supervised release.)

__________________________________________________________

__________________________________________________________________________________________________.
9. I request the Court change my name to: ____________________________________.

____________________________________________________________________
(If petition is only filed on your behalf go to Section D, sign and complete.) B. FOR MY SPOUSE 10. My spouse's current name is:

___________________________________; his/her date of birth is:____________________, ________.

11. My spouse's place of birth was:____________________________________________. 12. My spouse's current residence address is:___________________________________________________________________________. 13. My spouse has lived in Illinois since __________________________, __________. (Insert date.) 14. I will have published notice of my intention to apply to this Court for a change of name. A copy of that notice will be filed with Clerk of Court. 15. My spouse 16. My spouse 17. My spouse is has has is not required to register as a sex offender under the Sex Offender Registration Act (730 ILCS 150/1 et. seq.). has not been convicted of identity theft. has not been convicted of aggravated identity theft.

18. My spouse has has not been convicted or placed on probation for a felony or misdemeanor in the State of Illinois or any other state. (If you have been convicted or placed on probation give details including name of offense, date of conviction or probation, sentence imposed and date of end of sentence including parole or mandatory supervised release.)

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________.
19. I request the Court change my name to: ________________________________________. (OVER)

(Page 2 of 3) C. FOR MY CHILDREN Age Date and Place of Birth

(Rev. 2/23/09) CCCO 0039 B

20. Name of Child

__________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________

_______ _______ _______ _______

______________________________________ ______________________________________ ______________________________________ ______________________________________

(Use additional sheet if more than 4 children) 21. My Relationship to the child(ren) is:

______________________________________________________________________________
(Parent, Guardian, Head of Household where child has resided for 3 years)

22. I feel it is in the best interest of the Child(ren) that a name change occur because: _______________________________________________

_________________________________________________________________________________________________ _________________________________________________________________________________________________.
23. The name and address of each child's parents are: Name of Child A. __________________________________ B. __________________________________ C. __________________________________ D. __________________________________ Father Mother

___________________________________ ___________________________________ ___________________________________ ___________________________________

_____________________________ _____________________________ _____________________________ _____________________________

(If more than four children, attach additional sheet listing Name of Child, Name of Father and Mother of that child. This list should assign a letter to the child; for example child 5 should be assigned E and so forth.) Each Parent has: (The parents of a minor child whose name is sought to be changed must either consent in writing to the change of name or be given notice of the hearing date and time so tht the parent may appear and voice any objections. For each parent please place the letter that identifies the child on the line to indicate whether the parent has consented or received notice.)

__________ Consented to the change of name by signing this petition; __________ Received notice of this Petition and Court Date (Bring proof of service of notice dated at least 10 days before the court date to
court on hearing date.)

__________ Cannot be located and has received Notice of these proceedings by Publication (Affidavit detailing efforts to locate absent parent,
copy of notice provided to absent parent and proof of service of notice required to be presented in Court at hearing.) 24. I request that the Child(ren) name(s) be changed to: From: A. B. C. D. To: A. B. C. D.

_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________

_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
(OVER)

(Page 3 of 3)

(Rev. 2/23/09) CCCO 0039 C

D. SIGNATURE Under penalties of perjury as provided in Section 1-109 of the Code of Civil Procedure (735 ILCS 5/1-109) I certify that I have read the Petition for Change of Name filed by

_____________________________________________ and state all of the facts contained therein are true. __________________________________________________
Signature of Second Petitioner

_________________________________________________
Signature of Petitioner

_________________________________________________
Print Name

__________________________________________________
Print Name

_________________________________________________
Street Address

__________________________________________________
Street Address

_________________________________________________
City/State/Zip

__________________________________________________
City/State/Zip

E. AFFIDAVIT BY PERSON OTHER THAN PETITIONER State of Illinois Cook County

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(Print Name of Petitioner(s))

_____________________________________________________ being duly sworn on oath deposes and says that I am acquainted with _________________________________________________________________________________________________ _______________________________________________ who reside(s) at: ___________________________________________ _________________________________________________________________________________________________
who is/are the petitioner(s) in this cause, and who has/have signed this petition; that I read this petition and know the contents thereof, and the matters and things stated therein are correct to the best of my knowledge and belief.

____________________________________________________
Affiant

Subscribed and sworn to before me this ____________ day

of

________________________________________, __________.

Atty. No.: __________________ Name

______________________________________________________
Notary Public

_______________________________________________

Atty. for: ________________________________________________ Address: _________________________________________________ City/State/Zip: __________________________________________ Telephone: _____________________________________________

DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS