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Vermont Name Change Petition Form

Applying for a new name in Vermont entails the use of this form. Filing fee varies from county to county. As such, applicant must inquire from the county court clerk’s office nearest her/his residence to ascertain the exact payment.Download

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Pc	122		
STATE	OF	VERMONT	
SUPERIOR	COURT	 	 																														PROBATE	DIVISION		
Unit																																																																										
	
Unit	Docket	No.____________	
	
In	re	____________________________________________		of	_______________________________	
   
	
PETITON	OF	ADULT	TO	CHANGE	NAME	
 
The undersigned petitioner represents as follows: 
That I was born at ________________________ on _______________; 
             	
town/city and state                                                        date of birth 
 	
That I have the following minor children, who were born in the following locations: 
 
Name of child    town/city and state    date of birth  
______________________________________________________________________________________________________________________________ 
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________ 
 
That I am married to __________________________________ of ______________________________ 
 
That the name I wish to be known by is: ___________________________________________________ 
 
That I understand that by filing this petition I consent to the court’s requesting the Department of 
Public Safety to determine whether the petitioner’s name appears on the sex offender	
 registry 
established by 13 V.S.A. § 5402 and to disclosure of the information to the court by the department; 
and I understand that, if the department reports that the petitioner’s name appears on the registry, 
the court shall permit the department to appear o the question whether there is a 	
compelling reason 
for granting the petition. 
 
 
Date: __________________  Signed: _____________________________________,Petitioner 
     Print Name: _________________________________ 
     Mailing Address: _____________________________ 
     ___________________________________________ 
     Telephone/email:_____________________________	
	
		
At __________________________ on this ______ day of ___________________, 20____, 
_________________________________________ personally appeared before me and acknowledged 
this instrument by him/her signed, to be his/her free act and deed. 
 
 
     ____________________________________________ 	
																																																										Judge/Register 
10/11 SML 
Next: Virginia Living Will Form Previous: Vermont Name Change Instructional Form
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