Name Change - 44C01-1302-MI-3

IN THE LAGRANGE CIRCUIT COURT

CASE NO. 44C01-1302-MI-3

STATE OF INDIANA                     )

                                                  )SS:

COUNTY OF                                 )

IN RE: THE NAME CHANGE OF:    )

Dylan Ross Smallwood               )

                                                  )

                                                  )

           Petitioner.                       )

VERIFIED PETITION FOR

CHANGE OF NAME

      Petitioner, Dylan Ross Smallwood, pro se, respectfully petitions this court to change his/her name. In support of this Petition, Petitioner states as follows:

     1. That my current name is: Dylan Ross Smallwood.

     2. That my date of birth is: 1/28/1990.

     3. That my Indiana driver’s license number/Indiana identification card number is Dylan R. Smallwood; and I will bring my Indiana driver’s license or identification card to my Change of Name Hearing for verification.

     4. That my mailing address is:

          9995 East 100 North___________

          LaGrange, Indiana 46761_______

And, if different, my residence address is:

          ___________________________

          ___________________________

     5. The following is a list of all my previous names:

     ______________________________

     6. That I (do) (do not) hold a valid United States passport. My proof that I am a United States citizen is_________. I will bring this document to my Change of Name Hearing for verification.

     7.  That the following judgments of criminal conviction of a felony under the laws of any state or the United States have been entered against me, or I have stated immediately below that I have no felony convictions:

                  _______________________

     8.  That I am not seeking to defraud creditors by changing my name.

     9.  That I have published notice of my request for name change in a local publication as required by law, and will bring proof of publication to the hearing.

   10.  That I am not a sex or violent offender who is required to register under I.C. 11-8-8.

   11.  That pursuant to Indiana Code 34-28-2-1, I wish to change my name. The reason I want to change my name is:

My father’s last name is Hall and that is who I was raised by, not my biological father with the name of Smallwood.

   12.  That I wish to change my name to Dylan Ross Hall.

     WHEREFORE, I respectfully request that this Court grant my Petition for Name Change, and for all other just and proper relief. I affirm under the penalties of perjury that the foregoing representations are true.

          Dylan Ross Smallwood

          9995 East 100 North

          LaGrange, Indiana 46771

WC 382                                 S11,18,25