Florida Name Change Form

 


IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:

Division::

Petitioner,

and

Respondent,
PETITION FOR CHANGE OF NAME (ADULT)
I, {full legal name} certify that the following information is true.<
1. My complete present name is: I request that my name be changed to:
2. I live in County, Florida, at {street address}
4. My father’s full legal name:
My mother’s full legal name:
My mother’s maiden name:
5. I have lived in the following places since birth:
Dates(to/from)
/
/
/
/
Address
5. Please indicate here if you are continuing these facts on an attached page.
6. Family
{Indicate all that apply}
a. I am not married
b. I am married. My spouse’s full legal name is:
c. I do not have child(ren).
d. The name(s), age(s), and address(es) of my child(ren) are as follows (all children,including those over 18, must be listed):
Name {last, first,middle initial} Age Address, City,State
Please indicate here if you are continuing these facts on an attached page.)
7. Former names
{Indicate all that apply}
My name has never been changed by a court.
My name previously was changed by court order from To on {date}
by {court, city,and state}
A copy of the court order is attached.
I have never been known or called by any other name.
I have been known or called by the following other name(s):
{list name(s) and explain where you were known or called by such name(s)}
8. Occupation
My occupation is:
I am employed at: {company and address}:
During the past 5 years, I have had the following jobs:
Dates(to/from)
/
/
/
/
Address
Please indicate here if you are continuing these facts on an attached page.)
9. Business
{Choose one only}
I do not own and operate a business.
I own and operate a business. The name of the business is:
The street address is:
My position with the business is:
I have been involved with the business since:{date}
10. Profession
{Choose one only}
I am not in a profession.
I am in a profession. My profession is:
I have practiced this profession:
Dates(to/from)
/
/
/
/
Address
Please indicate here if you are continuing these facts on an attached page.)
11. Education
11. Education
Degree Received Date of Graduation School
Please indicate here if you are continuing these facts on an attached page.
12. Criminal History
{Choose one only}
I have never been arrested for or charged with, pled guilty or nolo contendere to, or been found to have committed a criminal offense, regardless of adjudication.
I have a criminal history. In the past I have been arrested for or charged with, pled guilty or nolo contendere to, or been found to have committed a criminal offense, regardless of adjudication. The details of my criminal history are:
Date City/State Event (arrest,charge, plea, or adjudication)
Please indicate here if you are continuing these facts on an attached page.)
13. Bankruptcy
{Choose one only}
I have never been adjudicated bankrupt
I was adjudicated bankrupt on {date}
, in {city}
{county} ,{state}
Please indicate here if you have filed additional bankruptcies,and explain on an attached page.)
14. Creditor(s)’Judgment
I have never had a money judgment entered against me by a creditor.
The following creditor(s)’ money judgment(s) have been entered against me
Date Amounts Creditor Court entering judgment and case number if paid {date}
Please indicate here if you have filed additional bankruptcies,and explain on an attached page.)
15. Fingerprints and Criminal History Records Check
Unless I am seeking to restore a former name, a copy of my fingerprints has been taken in a manner approved by the Department of Law Enforcement and submitted for a state and national criminal history records check.I understand that I cannot request a hearing on my Petition until the Clerk of Court receives the results of the criminal history records check.
16. I have no ulterior or illegal purpose for filing this petition, and granting it will not in any manner invade the property rights of others, whether partnership, patent, good will, privacy, trademark, or otherwise
17. My civil rights have never been suspended, or, if my civil rights have been suspended, they have been fully restored
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this petition and that the punishment for knowingly making a false statement includes fines and/or imprisonment
Dated:

Signature of Party,
Printed Name:
Address:
City,State,Zip:
Fax Number:
Designated E – mail Address(es):
STATE OF FLORIDA COUNTY OF
Sworn to or affirmed and signed before me on bY


NOTARY PUBLIC or DEPUTY CLERK


[Print, type, or stamp commissioned name of notary or
deputy clerk.]
Personally known
Produced identification

Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:[fill in all blanks]

 

This form was prepared for the: {choose only one} ( ) ( ) .This form was completed with the assistance of:
{name of individual}
{name of business}
{address}
{city} {state} {telephone number}


Your full legal name:
I am the:
Other Party’s legal name:
My address:
City, state, zip:
My Phone (area code and number):
My Fax (area code and number):
My email address(es):
My Occupation:
I’m employed by:
Business Address:


IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA


Petitioner,
and
Respondent.


Employment Information

If you have a different pay period than the choices given below, or your pay varies (for instance if you have more than one job and different pay periods), estimate your total average pay as closely as possible and convert it to a monthly pay amount. Enter it here as monthly.

If you receive a regular paycheck from an employer, then choose your pay rate and pay period below, and the income table will calculate monthly totals for you, based on your pay stub deductions. However, if you have multiple jobs with different pay periods, are self-employed, retired, etc, choose “monthly” here so that no further calculations will be done on your entries in the income table.
Pay rate $

Your Gross Monthly pay is $
If this doesn’t seem right, please double-check your entry, or calculate your monthly gross wages manually and enter it above as “Monthly”.

 

SECTION I. PRESENT MONTHLY GROSS INCOME
Attach extra sheets to your printed form, if needed to cover extra items and
descriptions. Items included under “other” should be listed separately with
separate dollar amounts. Where you calculate amounts, make sure and use MONTHLY
amounts for all the following sections, unless otherwise noted.
The online form makes conversions between other pay periods to monthy, as far as
possible.

1. Monthly gross salary or wages 1. $
0
2. Monthly bonuses, commission, allowances, overtime, tips and similar payments 2. $
3. Monthly business income from sources such as self-employment, partnerships, close corporations, and/or independent contracts (gross receipts minus ordinary and necessary expenses required to produce income) (Attach sheet itemizing such income and expenses.) 3. $
4. Monthly disability benefits/SSI received 4. $
5. Monthly Workers’ Compensation received 5. $
6. Monthly Unemployment Compensation received 6. $
7. Monthly pension, retirement, or annuity payments received 7. $
8. Monthly Social Security Benefits received 8. $
9. Monthly Alimony payment actually received      9a. From this case: $

9b. From other case(s): $

9. $ 0
10. Monthly interest and dividends received 10. $
11. Monthly rental income (gross receipts minus ordinary and necessary expenses required to produce income)
(Attach sheet itemizing such income and expense items.)		 11. $
12. Monthly income from royalties, trusts, or estates 12. $
13. Monthly reimbursed expenses and in-kind payments to the extent that they reduce personal living expenses 13. $
14. Monthly gains derived from dealing in property (not including nonrecurring gains) 14. $
15. Any other income of a recurring nature (list source) 15. $
16. Any other income of a recurring nature (list source) 16. $
17. PRESENT MONTHLY GROSS INCOME TOTAL: 17.  $ 0.00


SECTION I. PRESENT MONTHLY DEDUCTIONS

18. Federal, state and local income tax (corrected for filing status and allowable dependents
and income tax liabilities)
Add up your adjusted tax totals from your current IRS, State and local returns.
Do not
convert to monthly

$   

a. Filing Status

b. Number of dependents claimed    

 18. $
0.00 /month
19. FICA or self-employment taxes
Amount listed on your most recent pay stub:
 19. $ 0
/month
20. Medicare payments
Amount listed on your most recent pay stub:
 20. $
/month
21. Mandatory union dues
Amount listed on your most recent pay stub:
 21. $
/month
22. Mandatory retirement payments
Amount listed on your most recent pay stub:
 22. $
/month
23. Employer health  insurance payments, including
dental insurance. Exclude portion paid for any minor children of this
relationship, or insurance not provided by your employer.

Amount listed on your
most recent pay stub:
 23. $
/month
24. Monthly court-ordered child support actually paid
for children from another relationship		 24. $
/month
25. Monthly court-ordered alimony actually paid      25a. From this case: $
/month

25b. From other case(s): $

/month

 25. $
0
/month

26. TOTAL DEDUCTIONS
ALLOWABLE UNDER SECTION 61.30, FLORIDA STATUTES

(Add lines 18 through 25):
26. $
PRESENT NET MONTHLY INCOME : 26. $


SECTION II. AVERAGE MONTHLY EXPENSES

A. HOUSEHOLD:
Mortgage or rent $
Property taxes $
Utilities $
Telephone $
Food $
Meals outside home $
Maintenance/Repairs $
Other
 $
B. AUTOMOBILE:
Gasoline $
Repairs $
Insurance $
C. CHILD(REN)’S EXPENSES:
Day Care $
Lunch Money $
Clothing $
Grooming $
Gifts for holidays $
Medical/Dental (uninsured) $
Other
 $
D. INSURANCE:
Medical/Dental (Do not include insurance deductions from your paycheck) $
Children(ren)’s medical/dental $
Life $
Other
 $
E. OTHER EXPENSES NOT LISTED ABOVE:
Clothing $
Medical/Dental (uninsured) $
Grooming $
Entertainment $
Gifts $
Religious Organizations $
Miscellaneous $
Other
 $
Other  $
 Other $
 Other $
 Other $
 Other $
 Other $
F. PAYMENTS TO CREDITORS:
Creditor Monthly
Payment
 1.
 $
 2.
 $
 3.
 $
 4.
 $
 5.
 $
 6.
 $
 7.
 $
 8.
 $
 9.
 $
 10. $
 11. $
 12. $
28. TOTAL MONTHLY EXPENSES 28. $

SUMMARY

29. TOTAL PRESENT MONTHLY NET INCOME
(from line 27 of SECTION I. INCOME)		 29. $ 0
30. TOTAL MONTHLY EXPENSES
(from line 28 above)
30. $
0.00
31. SURPLUS
(if line 29 is more than line 30, subtract line 30 from line 29. This is the amount of your surplus. Enter that amount here.)		 31. $
32. (DEFICIT)
(if line 29 is less than line 30, subtract line 29 from line 30. This is the amount of your deficit. Enter that amount here.)		 $ ()

SECTION III. ASSETS AND LIABILITIES
Use the nonmarital column only if this is a petition for dissolution of marriage and you believe an item is “nonmarital,” meaning it belongs to only one of you and should not be divided. You should indicate to whom you believe the item(s) or debt belongs. (Typically, you will only use this column if property/debt was owned/owed by one spouse before the marriage. See the “General Information for Self-Represented Litigants” found at the beginning of these forms and section 61.075(1), Florida Statutes, for definitions of “marital” and “nonmarital” assets and liabilities.)


A. ASSETS:

butInfo

Description of Items.
List a description of each separate item owned by you (and/or your spouse, if this is a petition for dissolution of marriage).
LIST ONLY LAST 4 DIGITS OF ACCOUNT NUMBERS.
Check the box next to any asset(s) which you are requesting the judge award to you.
 Current Fair Market Value husband (Don’t check this column except for separate, non-marital items) wife (Don’t check this column except for separate, non-marital items)
$
$
$
$

$

$

$
$

$
  $
  $
  $
  $
  $
  $
Total Assets $0.00


B. LIABILITIES (DEBTS):

DESCRIPTION OF ITEM(S). List a description of each separate debt owed by you (and/or your spouse, if this is a petition for dissolution of marriage). LIST ONLY LAST 4 DIGITS OF ACCOUNT NUMBERS. Check the line next to any debt(s) for which you believe you should be responsible. Current Amount Owed husband (Don’t check this column except for separate, non-marital items) wife (Don’t check this column except for separate, non-marital items)
$

$

$
  $

$
  $

$
  $
  $
  $

$
  $
  $
  $
Total Debts $0.00


C. CONTINGENT ASSETS AND LIABILITIES:
INSTRUCTIONS: If you have any POSSIBLE assets (income potential, accrued vacation or sick leave, bonus, inheritance, etc.) or POSSIBLE liabilities (possible lawsuits, future unpaid taxes, contingent tax liabilities, debts assumed by another), you must list them here.


Contingent AssetsCheck the box next to any asset(s) which you are requesting the judge award to you.		 Possible Value husband(Don’t check this column except for separate, non-marital items) wife(Don’t check this column except for separate, non-marital items)
  $
  $
Total contingent Assets $0.00


Contingent LiabilitiesCheck the box next to any asset(s) which you believe you should be responsible.		 Possible Amount Owed husband(Don’t check this column except for separate, non-marital items) (Don’t check this column except for separate, non-marital items)
wife
  $
  $
Total contingent Liabilities $0.00


 

SECTION IV. CHILD SUPPORT GUIDELINES WORKSHEET
(Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet, MUST be filed with the court at or prior to a hearing to establish or modify child support. This requirement cannot be waived by the parties.)

I certify that a copy of this document was [check allused]“
to the person(s) listed below on {date}.

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
E-mail Address(es):

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this affidavit and that the punishment for knowingly making a false statement includes fines and/or imprisonment.

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [fill in all blanks]

full legal name of Non-Lawyer
Business
Street:
City:
State:
Phone:

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