Mississippi Name Change Petition Form

Mississippi Name Change Petition Form.pdf Use this form to start the name change process in Mississippi by filing this form with the county court clerk’s office and paying the filing fee. You will be




Change of Name of Adult Petition
State of _______________
County of ________________
Court _____________________________
Docket No. ________________________
Name of Petitioner(s): In re: Change of Name of Adult
First Middle Last
From: _______________________________
Previous Legal Name
To: _________________________________
New Legal Name
Petitioner(s) makes (make) the following declaration:
I. Petitioner’s Birth Name: The petitioner’s name at birth was
First Middle Last
and until the date of this petition, the petitioner has always been referred to as
this name or:
List Name(s) Petitioner has been known as (if any)
II. Birth Date and Place: The petitioner was born on _____________________,
In the City of _____________________, County of _______________________,
City County
State of _______________________.
StateIII. Petitioner’s Residency: The petitioner’s official legal address is
Street Address
City of ________________, County of _________________, State of _________
City County State
and has resided at this address for approximately _______ years.
IV. New Name & Reason for Name Change: Petitioner seeks to change name
Petitioner’s New Legal Name
for the following reason(s):
V. Outstanding Judgments: The Petitioner does not have any outstanding
judgments, has never been convicted of a crime, and is not involved in any
pending legal actions.
VI. Additional Declarations: In addition to the foregoing statements, the
Petitioner(s) further declares
Additional Declarations (if any)
NOW, THEREFORE, the Petitioner(s) requests (request) that the court order the
Petitioner’s name changed as follows:
From: ____________________________________________
Previous Legal Name
To: ______________________________________________
New Legal NameVerification (Petitioner)
Petitioner Legal Name
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.
Notary Acknowledgement
State of ___________ County of ______________________________ Subscribed,
Sworn and acknowledged before me by ______________________________, the
Principal, and subscribed and sworn to before me by ______________________,
witness, this ______________________ day of ________________________.
Notary Signature
Notary Public
In and for the County of ______________________________
State of ______________________________
My commission expires: ______________________________ Seal