About this Form:  In most jurisdictions, a Petition for Change of Name of Adult must be filed in the county court in which the Petitioner (i.e. the person seeking to change his or her name) lives.  Any lawful reason that the Petitioner deems a benefit is typically adequate to satisfy most courts.  For example, the Petitioner may prefer a new name due to social or religious reasons.  The Petitioner may not change his or her name for purposes of fraud or if it will violate the rights of others.  Some courts may require the Petitioner to provide a list of the names and addresses of his or her creditors.  The Petitioner should contact the court clerk in the county in which he or she resides to determine the filing fees, docket number, and other local requirements.

Petition for Change of Name of Adult

State of Mississippi
County of ________________
Court _____________________________
Docket No. ________________________
   
Name of Petitioner:_____________________________ In re:  Change of Name of Adult   
  From: _____________________________
To: _______________________________

Petitioner makes the following declaration:

1. Birth Date and Place:   Petitioner was born on _______________________, ______ in  ________________________ [city],  ________________________ [county], ________________________ [state]. A certified copy of petitioner's birth certificate is attached to this petition.

2. Birth Name:  Petitioner was named ____________________________________________ at birth, and as of the date of this petition, the Petitioner has always been known by that name, with the following exceptions, if any:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
[list all legal names previously held].

3. Residence:  Petitioner resides at _______________________ [insert residential address] and has lived at this address for ________ [insert length of time in months or years at this address].

4. Petitioner's Parents:  The father of the Petitioner is named ______________________________________________, and he resides at _____________________________________________________________________________ [insert residential address of father].  The mother of the Petitioner is named ______________________________________________, and she resides at _____________________________________________________________________________ [insert residential address of mother]. 

5. Reason for Name Change:  Petitioner seeks to change his or her name to ______________________________________________ and offers the following reason(s) for seeking to do so:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________.

6. Legal and Creditor Status:  Petitioner does not have any outstanding judgments, has never been convicted of a crime, and is not involved in any pending legal actions.

7. Additional Declarations:  In addition to the foregoing statements, the Petitioner further declares:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
[insert additional declarations, if any].

NOW, THEREFORE, the Petitioner requests that the court order the Petitioner's name changed as follows:

From: ____________________________________________
To: ______________________________________________


Verification

I, ______________________________________________[name of Petitioner], affirm under penalty of perjury that I am the Petitioner in the foregoing Petition to Change Name of Adult and that all statements in this Petition are accurate to the best of my knowledge.
 

_____________________________________________ _________________
Petitioner's Signature Date


_____________________________________________
Petitioner's Address, Line 1

_____________________________________________
Petitioner's Address, Line 2


Subscribed and sworn to before me on this ____ day of __________________, 20_____.
 
 
__________________________________
Notary