Affidavit for name change
I, ______________________________________________________________________, being first duly sworn or affirmed, depose and state:
1. That my present full legal name (including first, middle and last) is:
___________________________________________________________
2. That my name, as stated on my birth certificate is: ____________________
3. That I have changed my legal name from: _______________________to _________________ on _______.
4. That I was born on ________ in the city of ________ country of _______ state of _________.
5. That I presently reside at __________________________________________________________ I reside at this location since _____ my mailing address is: ______________________________
6. That my natural/adoptive (circle one) mothers full name, including any middle of maiden name is __________________________________________________________________________.
7. That my natural/adoptive (circle one) fathers full name is: ______________________________.
8. That during the last 10 years, I have used or have been addressed by the following names in the jurisdiction(s) and on the date listed below:
Name _________________________________________________________________________
Jurisdiction ___________________________________Date ___________________________
Name _________________________________________________________________________
Jurisdiction ___________________________________Date ___________________________
Name _________________________________________________________________________
Jurisdiction ___________________________________Date ___________________________
9. The following is a complete list of locations where I have resided during the last 10 years and the length of each residency.
Address: ___________________________________________City:________ State: __________
Length of residency: From: _________________________To:___________________________ Address: ___________________________________________City:________ State: __________
Length of residency: From: _________________________To:___________________________ Address: ___________________________________________City:________ State: __________
Length of residency: From: _________________________To:___________________________
10. That my current occupation is ____________________________________________________ that my current employer is _______________________________________________________ that my current employers address is ______________________________________________.
11. That the change of my name is requested is not:
a. For fraudulent and wrongful purpose.
b. Detrimental to the rights of or interest of any other person(s).
c. Prohibited by or violated of any judicial or administrative adjudication.
Notarized:
Date: _______ before me personally appeared ___________ whose former name was ________ known to me to be the same individual and who executed the foregoing instrument and duly acknowledged to me that it was executed for the purpose above stated, and duly sworn and herein that the statement therein contained are true.
State seal Notary public
