Virginia Adult Name Change Petition Form

To begin the name change process in the State of Virginia, applicant must submit this form to the county court clerk’s office. Filing this form entails the payment of a processing fee.Download

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FORM CC-1411 (MASTER, PAGE ONE OF TWO) 11/11  
  	 	
APPLICATION FOR  CHANGE OF NAME	 (ADULT)	 	COMMONWEALTH OF VIRGINIA  VA. CODE § 8.01-217   
 
VIRGINIA:  In the Circuit Court of the  	[  ]	 City   	[  ]	 County of 	........................................................................\
......	 	
 
IN RE:  	........................................................................\
.................................................................................... 	 (APPLICANT’S NAME) FIRST  MIDDLE LAST SUFFIX 
 
  COMES NOW, the applicant, 	........................................................................\
...........................................	 	
  
and after being duly sworn states under oath as follows: 
 
 
1. Applicant’s Birth Name: 	........................................................................\
....................................................... .	  	   	 	FIR ST    M ID DLE    L AST    S UFF IX  	 
2.  City or County  of Residence:   ........................................................................\
.......................................................................    
3. Residence Address: 	........................................................................\
.............................................................. 	   	      STREET  ADDRESS 	
........................................................................\
.......................................................................................... 	 	CITY    STATE   ZIP  CODE      COUNTRY   
    	
 
4. Mailing Address: 	........................................................................\
.................................................................	 	     	 	IF DIFFERENT FROM RESIDENCE ADDRESS 	
 
5a.   Date of Birth: 	........................................................	 5b. Place of Birth:	............................................................ 	
 
 
6.  Father’s Full Name: 	........................................................................\
.............................................................. 	   F IR ST    M ID DLE     L AST           S U FF IX     
7.  Mother’s Full Name: 	........................................................................\
.............................................................	 	    	FIRST     MIDDLE     MAIDEN                                  CURRENT  LAST           	    
Answer the following questions by checkin g appropriate “Yes” or “No” box and providing information as requested.    
8.  Have you ever been convicted of a felony?	........................................................................\
.......	[  ]	 Yes   	[  ] 	No 	
9.  Are you currently incarcerated?	 **	  ........................................................................\
................	[  ]	 Yes   	[  ] 	No 	
  If yes, indicate facility name: 	........................................................................\
................................................  	 
    Facility Location:	........................................................................\
................................................................  	
10.  Are you a probationer with any court?** 	........................................................................\
.........	[  ]	 Yes   	[  ]	 No 	
   If yes, indicate court name:  	........................................................................\
...................................................	 	
11.  Have you previously changed your name either by a prior application or by marriage?	......................	[  ] 	Yes   	[  ]	 No 	
  (If yes, attach court order or other documentation and indicate previous names): 
 .......................................................................\
....................................................... ....................................	 	  
** Applications of probationers and inca rcerated persons MAY be accepted if the  Court finds good cause exists for such 
application.  Attach explanatory documentation to the application

FORM CC-1411 (MASTER, PAGE TWO OF TWO) 11/11     
  WHEREFORE, the undersigned applicant further certifies under oath that this name change is not sought for any 
fraudulent purposes and will not infringe upon the rights of othe rs, and pursuant to § 8.01-217 of the Code of Virginia, 1950, 
as amended, the applicant requests that  the Court order a change of name from: 
 
 
........................................................................\
................................................................................................ 
                	FIRST                                                      MIDDLE                                                   LAST                                                      SUFFIX 	
to 	
 
........................................................................\
................................................................................................ 
               	FIRST                                                      MIDDLE                                                   LAST                                                     SUFFIX	 	
 
  ______________________________________________________________    	                  APPLICANT 	  
 
Commonwealth/State of 	.............................................................. 	
 
[  ]	  City  	[  ]	  County of 	........................................................ 	
 
Subscribed and sworn to/affirmed before me this 	..................	 day of 	.................................................	, 20 	.................. 	
 
by 	........................................................................\
........................................................................................... 	
 
  ....................................................... ______________________________________________________________  	
                                 	DATE 	[  ]	  CLERK 	   [  ]	 DEPUTY CLERK 	
   	[  ]	  NOTARY PUBLIC My commission expires  ............................ 	
                                  Registration No.  ....................................