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Home My WebLink About12-3730Commonwealth of Pennsylvania County of Cumberland Name of Petitioner(s): Raza Imtiaz-Ahmad Khan Shumila Khan Court ?ol- 3730 ('iv I, 7e"M Docket No. In re: Change of Name of Minor From: Jehanzaib Khan To: Jehanzeb Imtiaz Khan PETITION FOR CHANGE OF NAME OF MINOR r Petitioner(s) makes (make) the following declaration: 1. Birth Date and Place: The minor was born on September 5 20 01 .- Town of North Hempstead [City], Nassau [county], New York [state]. A certified copy of the minor's birth certificate is attached to this petition. 2. Birth Name: The minor was named Jehanzaib Khan at birth, and as of the date of this petition, the minor has always been known by that name, with the following exceptions, if any: N/A list all legal names previously held]. 3. Residence: The minor resides at 1202 Gunstock Lane, Mechanicsburg, PA 17050 [insert the minor's residential address] and has lived at this address for 3 years [insert length of time in months or years at this address]. The Petitioner(s) resides (reside) at 1202 Gunstock Lane, Mechanicsburg, PA 17050 [insert residential address] and has (have) lived at this address for 3 years _ [insert length of time in months or years at this address]. 4. Minor's Parents: The father of the minor is named Raza Imtiaz-Ahmad Khan , and he resides at 1202 Gunstock Lane, Mechanicsburg, PA 17050 [insert residential address of father]. The mother of the minor is named Shumila Khan , and she resides at 1202 Gunstock Lane, Mechanicsburg, PA 17050 [insert residential address of mother]. 5. Reason for Name Change: Petitioner(s) seeks (seek) to change said minor's name to Jehanzeb Imtiaz Khan and offers (offer) the following reason(s) for seeking to do so: Correct the spelling of the FIRST name. Add MIDDLE name. 6. Legal and Creditor Status: The minor does not have any outstanding judgments, has never been convicted of a crime, and is not involved in any pending legal actions. 7. Additional Declarations: In addition to the foregoing statements, the Petitioner(s) further declares (declare): N/A [insert additional declarations, if any]. NOW, THEREFORE, the Petitioner(s) requests (request) that the court order the minor's name changed as follows: From: Jehanzaib Khan To: Jehanzeb Imtiaz Khan Verification (Petitioner #1) 1, Reza Imtiaz-Ahmad Khan [name of Petitioner], affirm under penalty of perjury that I am the (a) Petitioner in the foregoing Petition to Change Name of Minor and that all statements in this Petition are accurate to the best of my knowledge. Petitioner's Signature Da e 1202 Gunstock Lane, Mechanicsburg, PA 17050 Petitioner's Address, Line I Petitioner's Address, Line 2 Verification (Petitioner #2, if any) 1 S h u m i l a Khan [name of Petitioner], affirm under penalty of perjury that I am the (a) Petitioner in the foregoing Petition to Change Name of Minor and that all s)atements in this Petition are accurate to the best of my knowledge. C / ?- a0 Petiti ignature Date 1202 Gunstock Lane, Mechanicsburg, PA 17050 Petitioner's Address, Line 1 Petitioner's Address, Line 2 COMMONWEALTH OF PENNSYLVANIA COUNTY OF . . Subscribed and sworn to before me on this _L5 day of 20 1Z . Notary COMMONWEALTH OF PENNSYLVANIA Notarial Seal Saundra K. Defendener, Notary Public Chambersburg Wro, Franklin County My Commission 115"Ies Feb. 19, 2014 Member, Pennsylvania Association of Notaries Commonwealth of Pennsylvania Court County of Cumberland Docket No. Name of Petitioner(s): Raza Imtiaz-Ahmad Khan Shumila Khan In re: Change of Name of Minor From: Jehanzaib Khan To: Jehanzeb Imtiaz khan CONSENT TO CHANGE OF NAME OF MINOR I make the following declaration: 1. Name: My name is Jehanzaib Khan , and as of the date of the signing of this Consent, I have always been known by that name, with the following exceptions, if any: NSA 2. Residence: I reside at 1202 Gunstock Lane, Mechanicsburg, PA 17050 [insert the residential address] and have lived at this address for 3 years in months or years at this address]. [insert length of time 3. Consent to Change of Name of Minor: I am fully informed of the legal consequences and effects, and I give my consent to the request of the Petitioner(s) to change the name of said minor child as follows: From: Jehanzaib Khan To: Jehanzeb Imtiaz Khan Verification 1 Jehanzaib Khan [name of individual granting his or her consent], affirm under penalty of perjury that all statements in this Consent to Change of Name of Minor are accurate to the best of my knowledge. .'y 2han zeb ???n (6 2012 Signature Date 1202 Gunstock Lane, Mechanicsburg, PA 17050 Address, Line I Address, Line 2 COMMONWEALTH OF PENNSYLVANIA COUNTY OF ?? Subscribed and sworn to before me on this (j day of 20 ( 2i* T- Notary COMMONWI Notarial Seal -- Saundra K. Delenderfer, Notary Public Chambersburg Boro, Franklin County My Commission Explres Feb. 19, 2014 Recopied District New York State Department of Health F State File Number 2951 CERTIFICATE OF LIVE BIRTH Register Number p0 L __j IA. Name: s'"' tiraa? !e? 18. Medical Record No.: 2A Date of Butte: 28. Hour: ? 3t ZAIB 10 01397488 UPt, 5 2001 10:58% _2 Z Z ...2 Q ' 3. Sex:. 4A. Birth is: - 48. If No( Single: Birth is: 5. Platoe of Wirth: -a oil - male Sjxigie - 6A. Facility ;Name: 6B Locality: 6G. County of Bath: 1+TCtth Shore WV. HOSP. M? of PjoCtb . S 7A. Maiden Name MOM bw 78. Date of Birth: 7C. City and State Of Birth. D. Sceiat Security No.: JALI 109/23/2971. Pakistan 65-72-8814 aA. -a. Kichi liiCite of Detroit er f +r ese um ? to ?. m..,.n O sF. Street and Number of Residence: SF. Yes c T B 8 g 8703 THOMWOOD CP. 48312 8G. Masing Address: 8H. Zip Code. SL Wdical Record No.. 8703 TODEPWW CT., Star ' HM 48312 01444874 o 99A.. e?Name: 1?°ti?dae?O y??? 9B. Date of EWth9C. City end State it Birth: SD:Soc?iaipSe'cu?rintypNo.: ,,;E o gr P" 0/10/3-%3 ,P 1cR?. aw' I s. 1 OA. I CC1 that Bye stewinba"oti cons dsld is lroe to the my bWAWpe' t,oUef. 1, ned: 1 ame . 9W Attendant: 4 is t1 f 200, fl 101). Attendants NaniVRw ledee Irk Tide: 10E. License Number: U1 FI ZC [tAF> M. D. 087570 1 OF. Attendant's Mailing Address: 10G. Zip Code: a 179 COl M MIVE Great JPck, NY 11421 11A. Signature of the Registrar: 11 a. Date Filed:- 1-tC. information Added mended: f -1D. Date Amended: DOH 1363E (3194) ?? A 0401E 0 . . 2954 This is to certify that this is a true and Correct copy of the original Certificate of Birth on file in the Office of the Registrar, Town of North Hempstead, County of Nassau; State of New York. Signature : - Date: September 18, 2001 Michelle SChimel, Registrar of Vita Statistics ,No. 15406-2001 N.B. Do not accept this copy unless the raised seal of the Town of North :Yempswad is thermion of `aced VS Foan TlVH GR 712" W tclt vs Notadai Seal ry Pubfbc Chambersburg eoro, Franklin County r-01111116 Will K Member, Pennsvivanla Assodatiop of Notaries This is a copy of the above noted child's "Certificate of, Live Birth." (DOH 1963-E) N.Y.S. Department of Health regulation requires the Local Registrar send you this copy. Carefutty review this record for accuracy. Report discrepancies to: North Shore University Hospital f Michelle Schimel, Registrar Birth Cerfi irate Unit 1200 Ptandome Road (516) 562-8349 !Manhasset, New York 11030 1(516) 869-7650 IN RE: PETITION FOR IN THE COURT OF COMMON PLEAS OF CHANGE OF NAME CUMBERLAND COUNTY, PENNSYLVANIA JEHANZAIB KHAN : NO. 12-3730 CIVIL IN RE: PETITION FOR CHANGE OF NAME ORDER OF COURT AND NOW, this 21St day of June, 2012, upon consideration of the Petition for Change of Name, IT IS HEREBY ORDERED AND DIRECTED that a hearing will be held on Wednesday, September 5, 2012, at 8:30 a.m. in Courtroom No. 2 of the Cumberland County Courthouse, Carlisle, Pennsylvania. IT IS FURTHER ORDERED that notice of the filing of said Petition and the aforesaid date, time and place of the hearing be published once in the Cumberland Law Journal and a newspaper of general circulation in the County at least 10 days prior to the hearing; in addition, Petitioner shall comply with all other requirements of the C.C.R. P. 5, 54 Pa. C.S. §701, 702. By the Court, *jk, M. L. Ebert, Jr., ? Raza Imtiaz-Ahmad Khan Shumila Khan Parents, Petitioners bas Copy ma,/ed 4/atbz J. < IN RE: PETITION FOR IN THE COURT OF COMMON PLEAS OF CHANGE OF NAME CUMBERLAND COUNTY, PENNSYLVANIA JEHANZAIB KHAN : NO. 12-3730 CIVIL IN RE: PETITION FOR CHANGE OF NAME ORDER OF COURT AND NOW, this 5th day of September, 20121, after hearing on the Petition and on presentation of proof of publication of notice as required by law, and it appearing that there is no legal for other objection to the granting of the prayer of the petition, IT IS ORDERED AND DECREED that the name of Jehanzaib Khan is hereby changed to Jeha0zeb Imtiaz Khan. By the Court, M. L. Ebert, Jr., J. Raza lotiaz-Ahmad Khan Shumila Khan mow.. +!? `,..! Parents Petitioners +3 ;z -? F *1, c„ bas crx r z cn cam .' i??N 9s-ra =CD 3 ° r