APPLICATION FOR CHANGE OF NAME (ADULT)
Commonwealth of Virginia
VIRGINIA: In the Circuit Court of the [ ] City [ ] County of ..............................................................................
IN RE: ............................................................................................................................................................
(APPLICANT’S NAME) FIRST MIDDLE LAST SUFFIX
COMES NOW, the applicant, ...................................................................................................................
and after being duly sworn states under oath as follows:
- 1.
FIRST MIDDLE LAST SUFFIX
- 2.
STREET ADDRESS
..................................................................................................................................................................
CITY STATE ZIP CODE COUNTRY
- 3.
IF DIFFERENT FROM RESIDENCE ADDRESS
- 4a.
- 5.
FIRST MIDDLE LAST SUFFIX
- 6.
FIRST MIDDLE MAIDEN CURRENT LAST
Answer the following questions by checking appropriate “Yes” or “No” box and providing information as requested.
- 7.
- 8.
If yes, indicate facility name: ........................................................................................................................
Facility Location:........................................................................................................................................
- 9.
If yes, indicate court name: ...........................................................................................................................
- 10.
(If yes, attach court order or other documentation and indicate previous names):
..................................................................................................................................................................
** Applications of probationers and incarcerated persons MAY be accepted if the Court finds good cause exists for such
application. Attach explanatory documentation to the application.
WHEREFORE, the undersigned applicant further certifies under oath that this name change is not sought for any fraudulent purposes and will not infringe upon the rights of others, and pursuant to § 8.01-217 of the Code of Virginia, 1950, as amended, the applicant requests that the Court order a change of name from:
........................................................................................................................................................................
FIRST MIDDLE LAST SUFFIX
to
........................................................................................................................................................................
FIRST MIDDLE LAST SUFFIX
______________________________________________________________
APPLICANT
Commonwealth/State of ..............................................................
[ ] City [ ] County of ........................................................
Subscribed and sworn to/affirmed before me this .................. day of ................................................., 20 ..................
by ...................................................................................................................................................................
....................................................... ______________________________________________________________
DATE [ ] CLERK [ ] DEPUTY CLERK
[ ] NOTARY PUBLIC My commission expires ............................
Registration No. ....................................
