AOC-295 Doc. Code: PNC

Rev. 10-08

Page 1 of 1

Commonwealth of Kentucky

Court of Justice

www.courts.ky.gov

KRS Chapter 401

PETITION FOR NAME CHANGE

Case No. Court County IN RE: CHANGE OF NAME FOR _____________________________________________________________________

COME(S) THE PETITIONER(S), (choose one):

__________________________________________ and _____________________________________________,

living parents of the above-captioned minor (minor refers to child under age 18, see KRS 401.020); or

____________________________________________________, surviving parent of above-captioned minor; or

_________________________________________________________, guardian of above-captioned minor; or

above-captioned adult, AND IN SUPPORT OF THIS PETITION STATE(S):

1. The original name is .

2. The desired name change is .

3. Birthdate (MM/DD/YY) of minor/adult is .

4. Birth location (city, county, state) of minor/adult is: , , .

5. Minor/Adult currently resides in the county in which this Petition is filed. His/Her address is:

6. Purpose of desired name change is:

. I understand identity theft is a Class D Felony

in Kentucky. KRS 514.160. I am not requesting this name change to avoid a legal obligation or evade prosecution.

7. For petition of minor with two living parents: Per KRS 401.020, if a parent refuses or is unavailable to execute this

Petition, proper notice of its filing shall be made on absent parent pursuant to the Rules of Civil Procedure.

Father: Address:

Mother: Address:

WHEREFORE, Petitioner(s) pray(s) for an Order for Change of Name.

Dated: , 2 .

Petitioner’s Signature Petitioner’s Signature

Attorney Name:

HEARING

Schedule hearing for , 2 at a.m. p.m.

Judge

Subscribed and sworn to before me on

, 2 .

My commission expires: , 2 .

Notary Note: File this Petition in the Circuit Clerk’s Office in the county in where you reside.

Distribution for Hearing Notice: Petitioner(s) OR Attorney for Petitioner(s), if any