Indiana Name Change Petition Form

In the case of applying for a legal name change in the State of Indiana, the following form has to be completed and submitted.

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Form PS-34282-1 
  Revised by State Court Administration 10/10 
STATE OF INDIANA 
)  IN THE                                  CIRCUIT COURT 
  ) SS: 
COUNTY OF  )  CASE NO.  
 
 
IN RE THE NAME CHANGE OF:  ) 
          ) 
          ) 
          ) 
  Petitioner.       ) 
 
  VERIFIED PETITION FOR CHANGE OF NAME  
 
Petitioner, ________________________________________________, pro se, respectfully petitions 
this court to change his/her name.  In support of this Petition, Petitioner states as follows: 
  1.  That my current name is: ______________________________________. 
 
2.  That my date of birth is: _______________________________. 
 
3.  That my I ndiana driver’s license number/ Indiana identification card number is 
______________________________; and I will bring my Indiana driver’s license or identification card 
to my Change of Name Hearing for verification.   
4.  That my mailing address is :  ________________________________________________ 
  ________________________________________________ 
And, if different, my residence address is:  ________________________________________________ 
  ________________________________________________. 
 
5.  The following is a list of all of my previous names:  
__________________________________________________________________________________.   
6.  That I ________ hold a valid United States passport.  My proof that I am a United States 
citizen is __________________________.  I will bring this document to my Change of Name Hearing 
for verification.   
7.  That the following judgments of criminal conviction of a felony under the laws of any 
state or the United States have been entered against me, or I have stated immediately below that I have 
no felony convictions:  
__________________________________________________________________________________.   
8.  That I am not seeking to defraud creditors by changing my name. 
 
9.  That I have published notice of my request for name change in a local publication as 
required by law, and will bring proof of publication to the hearing. 
 
10.  That I am not a sex or violent offender who is required to register under I.C. 11-8-8.

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Form PS-34282-1 
  Revised by State Court Administration 10/10 
11. 
That pursuant to Indiana Code 34-28-2-1, I wish to change my name.  The reason I want 
to change my name is: 
__________________________________________________________________________________.   
12.  That I wish to change my name to___________________________________________. 
 
WHEREFORE, I respectfully request that this Court grant my Petition for Name Change, and for 
all other just and proper relief.  I affirm under the penalties of perjury that the foregoing representations 
are true. 
 
              ______________________________ 
              Signature 
 
              ______________________________ 
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