Declaration of Legal Name Change

I, the undersigned, declare that I am 18 years of age or older and further declare:
1. I, ______________________ [name presently used], was born ______________________ [name on birth certificate] in the County of _____________ [county where born] in the State of ___________ [state where born] on _____________ [birthdate, including year].
2. I HEREBY DECLARE that I have changed my legal name, and will be henceforth exclusively known as: ______________________ [new name].
3. My legal name change was completed by order of the ______________ County Superior Court in Case No. _______ on ____________. A coy of the court order is attached to this Declaration.
4. NOTICE IS HEREBY GIVEN to all agencies of the State of _____________ [state where you reside], all agencies of the federal government, all creditors, and all private persons, groups, businesses, corporations, and associations of said legal name change.
5. A copy of the court order is attached to this Declaration.
I declare under penalty of perjury under the laws of the State of _____________ [state where you reside] that the foregoing is true and correct.

_______________________________________________	_________________
Signature, new name	Date

_______________________________________________	_________________
Signature, old name	Date