Hawaii Fact Sheet Form

The following form has to be completed and submitted to the Lieutenant Governor’s Office in the State of Hawaii.

Extracted Text for Proper Search

Form A - eff: 11/18/2010 Page 9	
 
FACT SHEET 
 
Petitioner shall answer the following questions fully and completely and submit this FACT SHEET with 
your Petition for Change of Name. 
 
1.  What is the name on your Birth Certificate?     What is the File No?    Dated 
  _________________  
________________________________________  ____________ 
 
2.  What is the name on your Certificate of Naturalization?   What is the No?  Dated 
  ______________ 
______________________________________________   ____________ 
 
3.  What name appears on your social security card?  
 
4.  What name do you use in your employment?  
 
5.   List all of your marriages, divorces, dates and places thereof:      Date of Marriage	
 
    Place of Marriage	Married to
 
 
 
 
   Date of Divorce	
 
    Place of Divorce	Divorced From
 
 
 
 
6.  List the names, date and place of birth of all your living children: 
     Date of Birth	
 
     Place of Birth	Name
 
 
 
 
 
7.  What is the reason for legalizing this name change?  
  ________________________________________________________________________\
________ 
  ________________________________________________________________________\
________ 
 
8.   I was born/married in the State of Hawaii, and wish  to have the name on my birth certificate amended 
in the following way: (1) Birth Certificate (2) Marriage Certificate\
 
   ________________________________________________________________________\
_________ 
(1) 
 First name    Middle Name     Last Name  
 
      (2)  First Name Cannot be Amended ______________________________________________________   Middle Name    Last Name