IN THE LAGRANGE CIRCUIT COURT
CASE NO. 44C01-1302-MI-3
STATE OF INDIANA )
COUNTY OF )
IN RE: THE NAME CHANGE OF: )
Dylan Ross Smallwood )
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