Mississippi Name Change Petition Form




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