Page 1 of 3Petition for Name Change of a Minor Child DC 6:11.1 Rev. 01/2020

(county where Petition filed)

IN RE NAME CHANGE OF CASE No.___________________

(case number assigned by clerk of court)

______________________________ (minor child(ren)’s current full name(s))

PETITION FOR NAME CHANGE OF A MINOR CHILD OR CHILDREN

______________________________ ______________________________ ______________________________,

Minor Child(ren), By Parent or

Guardian

______________________________. (your full name)

I, _______________________________, on behalf of ____________________ (your full name)

______________________________________________________________________ (minor child(ren)’s current full name(s))

______________________________________________________________________

minor child(ren), and without the assistance of an attorney, ask this court for a name

change for the minor child(ren). In support of this Petition, I state that the following

items are true:

1. My address is _____________________________________________, (your present street address)

_____________________, ____________________County, Nebraska.

(city where you live) (county where you live)

PETITION FOR NAME CHANGE OF A MINOR CHILD

2. The minor child(ren)’s current name(s) is/are _______________________

_____________________________________________________________________ (minor child(ren)’s current full name(s))

______________________________________________________________________

Nebraska State Court Form

DC 6:11.1 Rev. 01/2020 Neb. Rev. Stat. § 25-21, 271

3. The minor child(ren)’s current address is __________________________, (minor child(ren)’s present street address)

____________________, ___________________ County, Nebraska. (city where minor child(ren) live(s)) (county where minor child(ren) live(s))

4. The minor child(ren)’s date(s) of birth is/are provided on the

Confidential Party Information Form (DC 6:11.7).

5. My relationship to the minor child(ren) is __________________________.(mother/father)

6. The minor child(ren) and I have been residents of ___________________

(county where you and minor child(ren) live)

County, Nebraska for more than one year prior to the filing of this Petition.

7. I desire that the court change the name(s) of _______________________

_____________________________________________________________________ (minor child(ren)’s current full name(s))

_____________________________________________________________________,

minor child(ren), to ______________________________________________________ (minor child(ren)’s preferred new full name(s))

_____________________________________________________________________

_____________________________________________________________________.

8. The other parent of the minor child(ren) is _________________________

___________________________________________________. (minor child(ren)’s other parent’s full name)

9. I desire to change the name(s) of the minor child(ren), _______________

______________________________________________________________________ (minor child(ren)’s current full name(s))

______________________________________________________________________

Page 2 of 3Petition for Name Change of a Minor Child DC 6:11.1 Rev. 01/2020

for the following reason(s):

(list here why you desire to change the minor child(ren)’s name(s))

________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

.

I request the court set this matter for hearing, and that upon

such hearing, enter an order changing the name(s) of the minor child(ren) from

_____________________________________________________________________ (minor child(ren)’s current full name(s))

_____________________________________________________________________

to ___________________________________________________________________ (minor child(ren)’s preferred new full name(s))

_____________________________________________________________________.

Date Petitioner’s Signature (your signature)

Your Full Name

Your Full Street Address/P.O. Box

City/State/ZIP Code

Phone E-mail Address

Page 3 of 3Petition for Name Change of a Minor Child DC 6:11.1 Rev.01/2020