IN THE COURT OF COMMON PLEAS OF LEHIGH COUNTY, PENNSYLVANIA

CIVIL DIVISION

:
IN RE:	CHANGE OF NAME OF	:
:	File No.
:

CONSENT FOR CHANGE OF NAME (MINOR CHILD(REN))

I, (full legal name)	, being sworn,
certify that the following information is true:
I am the birth or legal	father	mother of the minor child(ren) named in this case,
and I give consent for the following name changes:
Minor child(ren)’s complete present name(s):
Minor child(ren)’s name(s) to be change to:

I verify that the statements made in this Consent for name change of minor child(ren) are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities.

Date:
Signature of Consenting Parent
Print name:
Address:
Telephone:

IN THE COURT OF COMMON PLEAS OF LEHIGH COUNTY, PENNSYLVANIA

Wotring-ra

2009-04-06

Lehigh County