LOREN JACKSON
HARRIS COUNTY DISTRICT CLERK
APPLICATION FOR CHANGE OF NAME CERTIFICATE
As provided in Section 45.106, Family Code, the undersigned person applies to the District Clerk for a change of name certificate. Cause Number: _________________________ Court Number: ____________________________ Driver's License Number: ____________________________________________________________ Social Security Number: _____________________________________________________________ Signature of Applicant: ______________________________________________________________
CHANGE OF NAME CERTIFICATE
Name of person before change of name was ordered: __________________________________________________________________________________
Name to which the person's name was changed by the court: __________________________________________________________________________________
DATE NAME CHANGE ORDERED: __________________________________________________ DRIVER'S LICENSE NUMBER: _____________________________________________________ SOCIAL SECURITY NUMBER: ______________________________________________________ I, LOREN JACKSON, Harris County District Clerk, hereby certify a name change was granted as reflected above.
________________________ Date
By: ___________________________________________ Deputy District Clerk
S:\FormsLib\Civil Bureau\Civ Fam Intake & Customer Svc\Customer Service\Application for Change of Name Certificate
Revised 11/18/08