VERIIFED PETITION FOR CHANGE OF NAME CASE NO. 20C01-1608-MI-000230 IN THE ELKHART CIRCUIT COURT FOR THE STATE OF INDIANA, COUNTY OF ELKHART, SS: IN RE THE NAME CHANGE OF: Blake Anthony Mason, Petitioner. Petitioner, Blake Anthony Mason , pro se, respectfully petitions this court to change his name. In support of this Petition, Petitioner states as follows: 1. That my current name is: Blake Anthony Mason. 2. That my date of birth is: 04/03/1995. 3.That I will bring my Indiana driver's license or identification card to my Change of Name Hearing for verification. 4. That my mailing address is: 1721 Canterbury Dr., Elkhart, IN 46514. 5.The following is a list of all of my previous names: Blake Anthony Mason. 6.That I do not hold a valid Untied States passport. My proof that I am a United States citizen is Birth Certificate. I will bring this document to my Change of Name Hearing for verification. 7.That the following judgments of criminal conviction of a felony under the laws of any state or the United States have been entered against me, or I have stated immediately below that I have no felony convictions: I have no felony convictions. 8. That I am not seeking to defraud creditors by changing my name. 9.That I have published notice of my request for name change in a local publication as required by law, and will bring proof of publication to the hearing. 10.That I am not a sex or violent offender who is required to register under I.C. 11-8-8. 11.That pursuant to Indiana Code 34-28-2-1, I wish to change my name. The reason I want to change my name is: The proposed name fits me better; therefore, I would like to be known by this name in all my personal and business affairs. 12.That I wish to change my name to: Blake Anthony Moore. WHEREFORE, I respectfully request that this Court grant my Petition for Name Change, and for all other just and proper relief. I affirm under the penalties of perjury that the foregoing representations are true. Blake Anthony Mason 1721 CanterburyDr. Elkhart, IN 46514 August 17, 24, 31 hspaxlp
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