STATE OF VERMONT
DISTRICT OF____________________, SS.

PETITION OF ADULT TO CHANGE NAME

That I was born at ________________________ on _________________;town/city and state date of birth

The undersigned petitioner represents as follows:

That I have the following minor children, who were born in the followinglocations:

Telephone (_________________________________ At ________________________ On this ________ day of ______________, 20 ______, _______________________________ personally appeared before me and acknowledged this instrument, by him/her subscribed, to be his/her free act and deed.

Town of Residence __________________________

Mailing Address ____________________________

Print Name _________________________________

Dated ___________________ Signed ____________________________________________Petitioner

That the name I wish to be known by is:___________________________________.

That I am married to ______________________________________________________ of __________________________________________________________________________.

name of child town/city and state d/o/b

Judge/Register