STATE OF LOUISIANA 24th Judicial District Court for the Parish of Jefferson No.: _________________
Division: “_______”
________________________________________________________ vs. PAUL D. CONNICK, JR., DISTRICT ATTORNEY
PETITION FOR NAME CHANGE I. Petitioner,
_________________________________________________________,
born
on
__________________________, _________, with social security number _____________________, and domiciled in Jefferson Parish, Louisiana, wants to change his (her) name to _____________________________________________ for the following reason(s): II. [State reason(s) for name change here.]
III. This proceeding is brought under LSA—R.S. 13:14751-13:4755, and it is thus mandatory that the district attorney of this parish be served with a copy of this petition and be cited to answer it. WHEREFORE, petitioner prays for judgment changing his (here) name from _________________________________________ to ________________________________________. RESPECTFULLY SUBMITTED: Indicate attorney’s name, address, phone number and bar number OR If petitioner is representing himself, indicate petitioner’s name, address, and telephone number.
PLAINTIFF TO MAKE HAND-DELIVERY SERVICE TO DISTRICT ATTORNEY: The Hon. Paul D. Connick, Jr. District Attorney, 24th Judicial District Court 200 Derbigny St. Gretna LA 70053
_____________________________________ Signature _____________________________________ Printed Name _____________________________________ Address _____________________________________ City/State/ZIP Code _____________________________________ Telephone Number
STATE OF LOUISIANA 24th Judicial District Court for the Parish of Jefferson No.: _________________
Division: “_______”
___________________________________________________ vs. PAUL D. CONNICK, JR., DISTRICT ATTORNEY
JUDGMENT The Court, having considered the Petition for Name Change, together with the answer filed by the District Attorney for the 24th Judicial District Court in and for the Parish of Jefferson, State of Louisiana, and for the reasons assigned this date: IT IS ORDERED, ADJUDGED AND DECREED, that there is judgment herein, granting the
Petition
for
Name
change,
and
changing
the
legal
name
of
___________________________________________ to ______________________________________, pursuant to the provisions of Louisiana Revised Statute 13:4751, et seq. JUDGMENT READ, RENDERED, AND SIGNED AT GRETNA, LOUISIANA, this __________ day of the month of _____________________________, 20 ___.
_______________________________________________________ JUDGE, 24TH JUDICIAL DISTRICT COURT
