HomeMy WebLinkAbout15-0302 12
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Y L\V'PN
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
In Re: Civil Action - Law - NAME CHANGE
JEFFREY LOHR SMITH, NO.
01S'66 -.9— Civil Term
PETITION FOR NAME CHANGE
AND NOW, comes Jeffrey Lohr Smith, by and through his attorney, Jane
Adams, Esquire, and files this Petition to change her name, and hereby avers as
follows:
1. Petitioner, Jeffrey Lohr Smith, currently lives at 114 E. Orange Street,
Shippensburg, Cumberland County, Pennsylvania, 17257.
2. Petitioner lives at that address with his wife, Rosella Gibbin, his wife's
parents, Ronad and Erna Yanick and his children, Mark Anthony Gibbin (16) and
Jeffrey Lohr Gibbin (17).
3. Petitioner's legal name, as listed on his birth certificate (See Exhibit A) is
Jeffrey Lohr Smith.
4. Petitioner's date of birth is September 22, 1963, and he is fifty-one (51)
years old.
5. When Petitioner was very young, Petitioner's mother separated from his
natural Father, Robert Maurice Smith, and married another man, whose last name was
Gibbin.
6. Since that time, almost fifty (50) years ago, Petitioner has informally and
consistently used the last name of Gibbin.
7. Petitioner recently went to apply for a job.
8. When Petitioner went to apply for a job, he could not produce a birth
certificate that listed the name he has been using for almost fifty (50) years.
9. Consequently, Petitioner could not obtain said job.
10. Petitioner is seeking permission to be excused from the requirement that
she publish notification of the request for name change and that the case be sealed
because: Petitioner has consistently used the last name Gibbin for almost fifty50
ears. Petitioner has no debts that are listed in his legal name of Smith and no
creditors or obligees (if any) know him by that name
11. Petitioner's wife and children have the last name of Gibbin.
12. Petitioner has no outstanding credit debt that could be avoided through a
name change. If anything, said requested name change could make it easier for
creditors or persons looking for Petitioner since he will now be able to obtain legal
documents in the name he has been using for so many years.
13. Petitioner has no outstanding federal or state tax debt that could be
avoided through a name change.
14. Petitioner knows of no detriment or harm that could come to a third person
if publication is excused and he changes his name.
15. Petitioner is requesting that her name be changed to Jeffrey Lohr Gibbin.
name. WHEREFORE, Petitioner requests that this Honorable Court Order change his
Respectfully submitted,
Date:
` an Adams, Esquire
. No. 79465
17 W. South St.
Carlisle, Pa. 17013
(717) 245-8508
ATTORNEY FOR
PETITIONER
WEST VIRGINtA STAT E
Dist.
....... -------
' I ... 0 STATISTICS
S16-1 N,..l UVE s i fZ-r
—�21f-—---------- r
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(T7p le)
e Or
Jrnntj J eff (Middle)
re- WRITEO NOT �--T'Ilr7��'�AkjVJJ
Lohr
2. PLACE OF
i COUNTY
Ureenbri ler----------- 3- USUAL RESIDENCE OF-;0�HE�
b. COUNTY
I rnothe,live
OR LOCATION ?
-��-t Vir,-inia
b- CITY,TOWN. A. STATE' d.;,
TY ',-;—een.
RonCelrerte c- C11'Y,TOWN, OR LOCATION --------—
c. NAME OF -------------------- L=wj
HOSPITAL OR f"Or in hospital,give street 4diressj - Lsburq
INSTITUTION Greenbrier Valley d. r r-11 L ADDRESS
d. IS r&.^L;h OF III
ATH INSIDE CITY LIMITS?
YES El No
------------ 0 CITY
M!..ISLX 5a- THIS BIRTH --- YES M NO is :IESIDENCE ON A FA
-Le 5b. YES 0 NO
Single ff Twin Tri❑ plet o Ti—T-Fi-—`OIT-Pl.",Was Child Born— 6. DATE
IST 0 2r. (MoRth)
NAME 3-0 C fPOY) (Year)
7- (First) (Middle; I OF BIRTH I I c,�
Robert, (Last) -------
9. AGE t si --yaurice $
Mi.L I a- COLOR OR P�!,CE
L jo. BrRTmpLAC8(State or foreign WUn�
of this birth) Jh
37 YEARS I-t'l 02--J d a
la- USUAX cc: Ilb- Kind of Business k 2—up"Txo"
12. MAIDEN NAME 9 S. ArMT Men Or lr�dujtry
(First).
(Middle) (Last)
13. COLOR—6R—RACE
0
C 7r of h�
14. ACE UoVer
E ——————
'r Of this birth) .,�5. BunTRPLAC. S,4!te or foreign cou
3. YEARs es-L, 101)1 16. Pre,..,Deliveries
INFORMANT
r277'nis
HT r(Do
A 0 Mot 0 NOY include this bj,j,)
I'JO I
b. How "tany OTHER
110 chda. How y i children e b c. How man, f
ren no (fetuses born licad W ANY
i
in b ar e no U,d,ad`7
Shiela Sn`Lth time after cocpnionp
18. MOTHER'S MAILIN L 0
�ew"J-s bur? West Vil,-ginia
certify1 hereby l8a. $IGkATAJRE
that :this child
,.", !�i 18b. ArrENDAN7
was b LZVC AT BIRTH
t h e d a t e (.6 OTHER
stated ab t_ 18c. ADDRESSM.D. pg D.0. C)
MIDWIFE CD (Specify)
Roncevert I 8d. D SIGNED
19. DATE RECD BY LOCAL-Rrr 1 u--- rini a
SICNATU)RE
M S 2
ON uICH'ElViN NAME ZDED
nY (Registrar)
-----------—�,neg
I hereby certify that the above is a true photos aphic
copy of a record filed Nvith the Vital i
Ret..o .stration
Office, Bureau for Public Health, Charleston.
West Virginia.
Witness my hand and sClai this fifth day of
August 1997.
�7
—7
Gary L. Tiorripson. State Registrar
VERIFICATION
I verify that the statements made in this petition are true and correct. 1
understand that false statements herein are made subject to the penalties
Pa.C.S. §4904, relating to unsworn falsification to authorities.
i of 18
es.
Date: `
� � � �• � J L rS � �
meth, Petitioner
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
In Re: _ Civil Action - Law - NAME C Hey
JEFFREY LOHR SMITH, NO. � � '
erm
PRAECIPE TO PROCEED IN FORMA PAUPERIS
r -
To the Prothonotary:
Kindly allow Petitioner, Jeffrey Lohr Smith, to proceed in forma pauperis.
This case was referred by the Pro Bono Program of the Cumberland County Bar
Association. I, Jane Adams, attorney for the party proceeding in forma pauperis, certify that I
believe the party is unable to pay the costs and that I am providing free legal services to the
party. The party's affidavit showing inability to pay the costs of litigation is attached hereto.
Respectfully submitted,
Date: �� vA An
C),6 'Jarlisle,
Adams, Esquire
o. 79465013
South St.
Pa. 1.
(717) 245-8508
ATTORNEY FOR PETITIONER
-F
t
Y
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
In Re: Civil Action - Law NAME CHANGE
JEFFREY LOHR SMITH, NO. P1 5"'-66 36 Civil Term
AFFIDAVIT IN SUPPORT OF PETITION
FOR LEAVE TO PROCEED IN FORMA PAUPERIS
1. 1 am the Petitioner in the above matter and because of my financial condition I am
unable to pay the fees and costs of filing for this proceeding.
2. 1 am unable to obtain funds from anyone, including my family and associates, to pay
the costs of litigation.
3. 1 represent that the information below relating to my ability to pay the fees and costs
is true and correct.
(a) Name: Jeffrey Lohr Smith
Address: 114 E. Orange St., Shippensburg Pa 170257
(b) Social Security Number: not provided in this document due to privacy concerns
4. 1 am presently employed as a bagger part time at Giant
5. 1 earn approximately $120 gross income weekly, working 12 hours at
$10 per hour.
6. 1 have no other personal source of income. My wife receives $722/mo. In
disability.
7. Our total household income is approximately $1200 per month gross.
I do receive food stamps.
8. My monthly expenses are: $510 per,month in rent, and approximately $350 per
month in food basic clothing and toiletries, and approximately $200 per month in
utilities.
9. 1 have no other property or resources from which I could withdraw funds to pay for
the filing and legal fees of this matter.
10. The persons who are dependent on me for support are: my wife, who is on social
security disability.
11. 1 understand that I have a continuing obligation to inform the court of improvement
in my financial circumstances which would permit me to pay the costs incurred herein.
12. 1 respectfully request permission to proceed /n Forma Pauperis.
v
VERIFICATION
I verify that the statements made in this petition 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: ��. a Fj. `(� J y L r Smith, Petitioner
I