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I make the following declaration: 1. Name: My name is _________________________, 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: 2. Residence: I reside at _________________________ [insert the residential address] and have lived at this address for _______ [insert length of time in months or years at this address]. 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:
Verification I, ___________________________ [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.
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