Form Cafc402 – Fill Out and Use This PDF

The minor child is a resident of the following county in the State of Missouri:

If this is an amended petition, what is the case number of the pending case?

In the Circuit Court of

MISSOURI

Case Number		Division Number

Your Information

1.My full legal name is: (You are the “Next Friend” in this case.)

__________________	______________	_____________________________	________
(First Name)	(Middle Name)	(Last Name)	(Jr./Sr./III)

2.	I am the mother of the child.
	I am the father of the child.
	Other: __________________________________________________________
3. My mailing address is:
	___________________________________________________________________________________
	(Street)
	_____________________________________		______________________	_______________
	(City)		(State)	(Zip)
	_________________________	___________________________________________________
	(Telephone Number)	(E-Mail Address)

4. The other parent of the child has signed CAFC411 “Consent to Minor Child’s Change of Name” which is attached hereto.

The other parent of the child has NOT signed CAFC411 “Consent to Minor Child’s Change of Name” and therefore notice of hearing must be sent to him or her by the clerk of court.

5. The other parent’s full legal name is:

__________________	______________	_____________________________	________
(First Name)	(Middle Name)	(Last Name)	(Jr./Sr./III)

6. The other parent’s mailing address is:

___________________________________________________________________________________

(Street)

_____________________________________		______________________	_______________
(City)		(State)	(Zip)
_________________________	___________________________________________________
(Telephone Number)	(E-Mail Address)

Information about the Child

Residence Information

Form CAFC402-06/07/2013

7.The child’s full legal name is: (The child is the “Petitioner” in this case.)

__________________	______________	_____________________________	________
(First Name)	(Middle Name)	(Last Name)	(Jr./Sr./III)

8. The child wants to change his or her name to:

__________________	______________	_____________________________	________
(First Name)	(Middle Name)	(Last Name)	(Jr./Sr./III)

9.	This is the first petition that has filed in this case. (Original Petition)
	This is the second petition that has filed in this case.
10.The child’s mailing address is:
	___________________________________________________________________________________
	(Street)
	_____________________________________		______________________	_______________
	(City)		(State)	(Zip)
	_________________________	___________________________________________________
	(Telephone Number)	(E-Mail Address)

11.The child’s mother’s full maiden name is:

__________________	______________	_____________________________
(First Name)	(Middle Name)	(Last Name)

12.The child’s father’s full name is:

__________________	______________	_____________________________	________
(First Name)	(Middle Name)	(Last Name)	(Jr./Sr./III)

13.The child’s birth date is: (mm/dd/yyyy) ________________________

14.The child’s place of birth is: (City) ____________________(State)_______________

15.The change of the child’s name would not be detrimental to any other person.

16.The child resides in the Country of ________________.

17. The child resides in the State of ___________________.

18. The child resides in the County of ______________________.

Petition for Change of Name – Page 2 of 4

This form is available for free at www.selfrepresent.mo.gov

Information about Previous Names

Additional Information

19.Check one of the two boxes.

The child’s name has never been changed.

The child’s name has previously been changed as follows: (State when and where and by what court)

_____________________________________________________________________________________

_____________________________________________________________________________________

20.Check all boxes that apply.

The child is the victim of a crime based upon domestic violence as defined in §455.200, RSMo.

The child is the victim of a child abuse as defined in §210.110, RSMo.

The child is the victim of abuse by a family or household member as defined in §455.010, RSMo.

21. The minor child wants to change his or her name because:

_____________________________________________________________________________________

_____________________________________________________________________________________

Information about Judgments and Cases against Me

22.Check one of the two boxes.

There are no unsatisfied money judgments against the child.

There are unsatisfied money judgments against the child in the following cases: (State the style of the case in which the judgment was entered and the court in which the judgment was entered.)

_____________________________________________________________________________________

_____________________________________________________________________________________

23.Check one of the two boxes.

There are no cases pending against the child requesting money.

The following cases are pending against the child in which money is requested: (State the style of the case and the court in which it is pending)

_____________________________________________________________________________________

_____________________________________________________________________________________

Request for Relief

Form CAFC402-06/07/2013

THEREFORE, I want the court to change the child’s name from the name stated in Paragraph 7 above to the name stated in Paragraph 8 above.

Petition for Change of Name – Page 3 of 4

This form is available for free at www.selfrepresent.mo.gov

Subscribed and sworn to this ___________ day of __________________, 20____.

________________________
Notary Public	Sign this in front of a
	Notary Public
My Commission Expires:
_____________________

This should only be completed if a lawyer helped you with this form

ATTORNEY INFORMATION (To be completed by your attorney)

______________________________________________	___________________
Attorney – SIGN HERE	Missouri Bar Number

_____________________________________________________________________

Attorney for Movant – PRINT YOUR NAME HERE

______________________________________________________________________________

(Street)

______________________________________		______________________	__________
(City)		(State)	(Zip)
__________________	_______________	_____________________________________
(Telephone Number)	(Fax Number)	(Email Address)

Do not enter any information here if you are filing this case without the assistance of a lawyer.

This information should be completed by your attorney.

I have assisted Petitioner in the preparation of these pleadings, but I am not entering my appearance on behalf of Petitioner.