__________________________ (Filing Persons Name)

__________________________ (Mailing Address)

__________________________ (Mailing City, State, Zip)
(
)-____________________ (Phone Number)
*****************************************************************************
STATE OF WYOMING
)
IN THE DISTRICT COURT
) ss
COUNTY OF _______________
)
__________JUDICIAL DISTRICT
******************************************************************************
IN RE THE NAME CHANGE OF:
)
_________________________________, )
Civil Action No. _______________
)
(your name)
)
Petitioner.
)
)
)
)
VERIFIED PETITION FOR CHANGE OF NAME

Petitioner, ______________________________ (your name), Pro Se, respectfully petitions this

Court to change his/her name. In support of his/ her Petition, the Petitioner states as follows:

1.

That my current name is: _______________________________________ (your current name).

2.

That I physically currently reside at: __________________________________________

______________________________________ (your current physical address).

3.

That I have been a resident of _______________ County, in the state of Wyoming from
___/___/_____ to______________ which is ______________________ length of time.

4.

That per Wyo. Statute Ann. 1-25-102, I fulfill the residency requirements necessary in
order to apply for a change of name; chiefly, I have lived in this County for the last two
years preceding the filing of this Petition.

5.

That pursuant to Wyo. Statute Ann. 1-25-101, I wish to change my name.

6.

That I am not seeking to defraud creditors or someone else by changing my name.

Form 1601

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Verified Petition for Change of Name

7.

That my reasons for the desired name change are the following: ___________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________.

8.

That I wish to change my name to: __________________________________________.

9.

That my place of birth is______________________(City), __________________ (County),

_______________(State), _________________________________(Country).
WHEREFORE, I respectfully request that this Court grant my Petition for a Change of

Name, and for all other relief which is just and proper. I further affirm that all the above facts
are true and correct to the best of my knowledge.
Respectfully Submitted this _________ day of ____________, 20____.

That Petitioner, ___________________________, (print your name) under the penalty of perjury,
verifies that she/he has read the Verified Petition for Change of Name, knows the contents of the
Verified Petition for Change of Name, and that the statements in the Verified Petition for Change
of Name are true to the best of her/his knowledge. (Truthfulness. It is absolutely essential that
you be completely honest and accurate in completing all forms. There are penalties for
attempting to mislead the Court. You should read Wyoming Rules of Civil Procedure, Rule
11[representations
to
Court]
and
Wyoming
Statute
6-5-301[perjury].)
I,
_________________________________________, (print your name) hereby certify that the above
stated facts are true and correct as to the best of my knowledge.
_______________________ (Signature in front of Notary / Court
Clerk of Petitioner)
_______________________ (Printed Present Name of Petitioner)
__________________________ (Mailing Address)
__________________________ (Mailing City, State, Zip)
(
)-____________________ (Phone Number)

STATE OF WYOMING
COUNTY OF __________

Form 1601

)
)ss
)

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Verified Petition for Change of Name

The foregoing document was acknowledged, subscribed and sworn to before me by

__________________________, personally and in person, this __________ day of
______________________, 20_____.
WITNESS my hand and official seal.
_____________________
Notary Public/Court Clerk
My Commission Expires:

-----------------------------------------------------------------------------------------------------------Pursuant to Rule 102 (a)(1)(B) of the Wyoming Uniform Rules of District Court the following
attorney has participated in the preparation of this pleading but said attorney is NOT deemed to
have entered an appearance in this matter:
Attorney ____________________________
Wyoming State Bar Number: ____________
____________________________________
____________________________________
____________________________________
____________________________________
Dated _____________

Form 1601

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Verified Petition for Change of Name