This form is approved by the Illinois Supreme Court and is required to be accepted in all Illinois courts.

For Court Use Only

STATE OF ILLINOIS,
CIRCUIT COURT REQUEST FOR NAME CHANGE
COUNTY
(ADULT)

Instructions
Directly above, enter Request of:
the county name
where you will file
this case.
Enter your current
name.
DO NOT enter a Case Your current name (First, middle, last name)
Number, the Circuit Case Number
Clerk will add it.

In 1, enter your I ask the court to enter an order to change my name, and I state:
complete current
name. 1. My current name is:
In 2, enter the new full
name you would like.
First Middle Last
In 3, enter your 2. I wish my name to be changed to:
complete current
address.
In 4, enter the date First Middle Last
you started living in 3. My address is:
Illinois.
Street City State ZIP
In 5, enter the year 4. I have lived continuously in Illinois for at least 6 months beginning:
you were born.
Date
DO NOT enter your
entire date of birth. 5. My year of birth is:
In 6, enter the city, Year
county, state, and
country where you 6. My place of birth is:
were born. City County State/Province Country
In 7-9, check the 7. I  have  have not been adjudicated or convicted of a felony or
boxes that apply to
your criminal history. misdemeanor in Illinois or any other state for which a pardon has not been granted.
In 10, 11, and 12
check whether you 8. I  do  do not have an arrest for which charges have not been filed.
have or have not been
convicted or put on
probation for the
9. I  do  do not have a pending felony or misdemeanor charge.
crime listed.

If you checked “have” 10. I  have  have not been convicted of or placed on probation for a crime
in 10 or 11 and have
not been pardoned, the which requires me to register as a sex offender in Illinois or any other state.
court cannot give you
a name change.
11. I  have  have not been convicted of or placed on probation for identity
If you checked “have” theft or aggravated identity theft in Illinois or any other state.
in 12 and have not
been pardoned or have
not completed your 12. I  have  have not been convicted of or placed on probation for a felony in
probation or sentence
over 10 years ago, the Illinois or any other state.
court may not give
you a name change.

NC-R 303.3 Page 1 of 2 (01/18)

 Enter the Case Number given by the Circuit Clerk: _________________________________

In 13, describe what 13. If you checked "have" in 10, 11, or 12 complete the following:
you were convicted of
or placed on probation Description of Date of Sentence Received Date
for, if you checked Felony or Conviction or (include parole and Sentence Pardoned?
“have” in 10, 11, or Misdemeanor Probation supervised release) Completed (Yes or No)
12.
If you run out of
space, use a separate
piece of paper.

Under the Code of I certify that everything above is true and correct. I understand that making a false statement
Civil Procedure, 735
ILCS 5/1-109, making
on this form is perjury and has penalties provided by law under 735 ILCS 5/1-109.
a statement on this
form that you know to
/s/
be false is perjury, a
Your Signature Street Address
Class 3 Felony.
If you are completing
this form on a
computer, sign your Print Your Name City, State, ZIP
name by typing it. If
you are completing it
by hand, sign and
print your name. Telephone
Enter your complete
address and telephone
number.

NOTE
This section should VERIFICATION BY WITNESS
be filled out by
someone else, not the
person asking for a I,
name change. First Middle Last
Witness: Enter your
full name. certify that what is stated above is true and correct to the best of my knowledge and belief.
Under the Code of
Civil Procedure, 735 /s/
ILCS 5/1-109, Witness Signature
making a statement
on this form that you
know to be false is
perjury, a Class 3 Witness Name
Felony.

Witness: Sign and Street Address

print your name.
Witness: Enter your
complete address. City, State, ZIP

NC-R 303.3 Page 2 of 2 (01/18)

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