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CIVIL CASE INFORMA110N STATEMENT l>omestic RELA110NS CASES PLAINTIFF IN THE CIRCUIT COURT, COUNTY, WEST VIRGINIA I.

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CIVIL CASE INFORMA110N STATEMENT l omestic RELA110NS CASES IN THE CIRCUIT COURT, COUNTY, WEST VIRGINIA I. CASE STYLE: PLAINTIFF CASE# --~ Date of Filing Street
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CIVIL CASE INFORMA110N STATEMENT l omestic RELA110NS CASES IN THE CIRCUIT COURT, COUNTY, WEST VIRGINIA I. CASE STYLE: PLAINTIFF CASE# --~ Date of Filing Street Judge City State Zip Phone Number : ( ) ----~- Social Security #: vs. DEFENDANT Days to Answer Type of Service Street City State Zip Phone Number : ( ) Social Security#: Original and copies of complaint furnished herewith. I PLAINTIFF: DEFENDANT: I CASE NUMBER: I I. II. D D PLEASE CHECK HERE IF EITHER PARTY ls ASKING FOR CHILD SUPPORT OR ALIMONY. PLEASE CHECK HERE IF THERE IS A FAMILY VIOLENCE PROTECTIVE ORDER NOW IN EFFECT. D. TYPE OF CASE: 0 Contested Divorce/ AnnutmenU 0 Petition for Child Support Only 0 Establish or Modify Child Custody Separate Maintenance Visitation 0 Uncontested Divorce/Annulment/ 0 Temporary Petition for Relief 0 Grandparent Visitation Separate Maintenance 0 URESA - Initiating 0 Modification of Child Support 0 Contempt or Other Enforcement 0 URESA - Responding 0 Patemity/URESA Paternity 0 Other (Specify): IV. 1. Has eil.'!er party ever received AFDC in West Virginia or other states? DYes ONo DUnknown 2. Has eitt'1er party ever applied for services from the Child Advocate Office? DYes ONo DUnknown 3. List all minor children affected by this action: Name Date of Birth SSN v. DYes DNo DO YOU OR ANY OF YOUit CLIENTS OR WITNESSES IN THIS CASE REQUIRE SPEClAL ACCOMMODAtiONS Dtffi TO A DISABILITY OR AGE? IF YES, PLEASE SPECIFY: D Wheelchair accessible hearing room and other facilities D Interpreter or other auxiliary aid for the heating impaired D Reader or other auxiliary_aid for the visually imp~ired D Spokesperson or other auxiliary aid for the speech impaired D Other: Attorney Name.; Finn: ~ Address: Representing: D Plaintiff D Defendant Telephone: Dated: D Prn S.- Signature IN THE CIRCUIT COURT OF MONROE COUNTY, WEST VIRGINIA IN RE: Petition of: Forchangeofnameto: NOTICE OF CHANGE OF NAME CIVIL ACTION NO: Notice is hereby served in accordance with Chapter 48, Article 5, Section 1 of the Code of West Virginia of the intention of to change his/her daughter's/son's name from to The Petitioner will appear in person before the Judge of the Circuit Court of Monroe County, West Virginia, in accordance wit the petition, on the day of, 20_, at a.m./ p.m. or as soon thereafter as the same may be heard in support of the petition for change of name and anyone having any objection to any such change of name as set forth in this notice may appear on said date and make proper objections thereto. The date of hearing may be rescheduled without further notice or publication. Entered by the Clerk of said Court, 20 LETA GULLETIE-COMER Clerk of Court IN THE CIRCUIT COURT OF MONROE COUNTY, WEST VIRGINIA IN RE: Change of Name From to Civil Action No PETITION Comes now the Petitioner and petitions this Court to change the D Petitioner or the D Petitioner's child or ward's name from to In support of this Petition, the Petitioner states as follows: I. He/She is currently over/under the age of eighteen (18) years, having been born on II. D Petitioner has been a bona fide resident of Monroe County, West Virginia for at least one (1) year prior to filing of this petition. OR D Petitioner is a nonresident of Monroe County, West Virginia but was born or married in this county or was previously a resident of this county for at least fifteen (15) years. The name change is not for the purposes of avoiding debt or creditors. Ill. Petitioner is not a registered sex offender pursuant to any state or federal law. IV. identity. v. This name change is not for the purpose of avoiding any state or federal law regarding This name change is not sought for any improper or illegal purpose. VI. VII. The Petitioner is not a convicted felon in any jurisdiction. 0 Petitioner or the 0 Petitioner's child or ward has been known as ' VIII. and the change of name is requested for the following reasons: 0 Petitioner is a divorced woman who wishes to restore her maiden name. 0 OtherReason: WHEREFORE, your Petitioner pray s that the Court declare that he/she shall henceforth beknownas andforsuchotherand further relief as this Court may deem just and proper. PETITIONER ProSe VERIFICATION STATE OF WEST VIRGINIA COUNTY OF MONROE, TO-WIT: 'the Petitioner named in the attached Petition, being first duly sworn, says that the facts and allegations contained in the said Petition are true; except insofar as they are therin stated to be upon information and belief, he/she believes them to be true. PETITIONER ProSe Taken, subscribed and sworn to before me, the undersigned authority, this day of, 20. My commission expires: NOTARY PUBLIC IN THE CIRCUIT COURT OF MONROE COUNTY, WEST VIRGINIA IN RE: CHANGE OF NAME FROM TO ~ CIVIL ACTION NO: ORDER This day came the Petitioner, in person and testified that he/she was born on the day of ' (check the appropriate choice below) D That he/she has been a resident of Monroe County, West Virginia for more than one (1) year preceding the filing of his/her Petition herein; D That Petitioner is a non-resident of Monroe County, West Virginia but was born in Monroe County, West Virginia, married in Monroe County, West Virginia, and was previously a resident of Monroe County, West Virginia for at least 15 years; D That he/she desire to have his/her name changed from to It appearing to the Court that the above conditions are true, and that Notice of the application for the change of name of Petitioner has been duly published in the newspaper of general circulation in Monroe County, West Virginia, as required by law, the Court, having considered the Petition, is of the opinion that no injury will be done to any person by reason of the requested change of name; that a reasonable and just cause exists for said change of name; that such change is not desired because of any improper or illegal purpose; that Petitioner is not a registered sex offender pursuant to any state or federal law; that this name change is not for purposes of avoiding any state or federal law regarding identity; that this name change is not for purposes of avoiding debtors or creditors; the Petitioner is not a convicted felon in any jurisdiction; and this Court does hereby grant the relief prayed for in said Petition previously filed herein. It is, therefore, ADJUDGED, ORDERED AND DECREED that the name of ~----bechangedto ;thatthe said Petitioner shall henceforth be known by the name of and that a certified copy of this Order shall be filed in the Office of the Clerk of the County Commission of Monroe County, West Virginia, provided by law. Dated: ROBERT A. IRONS Circuit Judge
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