STATE OF INDIANA ) IN THE _____________ SUPERIOR/CIRCUIT COURT
)
SS:
COUNTY OF ______________ ) CASE
NO. ______________________________
IN RE THE NAME CHANGE OF: )
)
___________________________ )
Petitioner.
NOTICE OF FILING PROOF OF PUBLICATION
AND REQUEST FOR HEARING
Petitioner, _____________________________________, pro se,
states as follows:
1.
I have given notice of my Petition for Change of Name, pursuant to
Indiana Code 34-28-2-3(a).
2.
I have attached a copy of the published notice herein as Exhibit A.
3.
The attached notice has been verified by the affidavit of a
disinterested person.
4.
More than thirty (30) days have passed since the last required
publication of notice.
5.
I am requesting that this Court set a hearing to consider my Petition
for Change of Name.
WHEREFORE, I respectfully request that this Court set a hearing to
consider my Petition for Name Change, and for all other just and proper relief.
I affirm under the penalties of perjury that the foregoing representations are
true to the best of my knowledge and belief.
_____________________________
Signature
_____________________________
Print
your name
_____________________________
Mailing
address
_____________________________
Town,
State and Zip Code
_____________________________
Telephone
number, with area code
