HomeMy WebLinkAbout15-0236 IN THE COURT OF COMMON PLEAS OF r/ COUNTY, PENNSYLVANIA
CIVIL DIVISION -LAW
• tJ,
IN THE MATTER OF
PETITION FOR CHANGE OF NAME OF /
�. s{tGl�lliih amf.Y NO:COK
PETITION FOR CHANGE OF NAME
Petitioner , requests that this Court order a change of the
petitioner's name, pursuant to 54 Pa. Cons. Stat. Section 701, et52 , and in support thereof
makes the following the averments:
1. The petitioner was born on aakuL, 2 , 19�2and is over the age of
twenty-one years.
2. During the five years preceding the filing of this petition, the petitioner has resided
in the following places:
DATE ADDRESSES ,l-_/
�llp J024/ S•— 7* &Za &
iD— u M WJ24- 1;1/of
3. There are no judgments or decrees pending against the petitioner.
4. The Petitioner requests that his/her name be changed from -' thdk Z`lAWff to_
C'o�a�a
5. The reasons for the requested change of name are IX!V ej-
rI )b h0hor
Grit AA X-
WHEREFORE, the petitioner respectfully requests that this Court enter an Order
changing his/her name from ShelkhAgmer to i�614#A,
Petitioner
%1D l 1`l-1'1 916
FORM OF INDIVIDUAL ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF DAUPHIN
On this --cam-- day of jfg&A6&,_,
before me, L4`# the
undersigned officer, personally appeared
1��A�lJ
WE- known to me, or
satisfactorily proven, to be the person— whose name—,,
subscribed to the within instrument, and acknowledged that he—
executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seals.
COMMONWEALTH OF PE
NOTARIAL SEAL
PATTY WACHTEFi,Notary Public
SusquehannaTwp.,Dauphin County
My Commission Eacpires December 19,2017