Santella Mercurio STATE OF INDIANA SS: COUNTY OF CASS IN THE CASS CIRCUIT COURT CASE NO. 09C01-1609-MI-44 IN RE THE NAME CHANGE OF: Marycarmen Isabelle Santella Mercurio Petitioner, VERIFIED PETITION FOR CHANGE OF NAME Petitioner, Marycarmen Isabelle Santella Mercurio, pro se, respectfully petitions this court to change his/her name. In support of this Petition, Petitioner states as follows: 1.That my current name is Marycarmen Isabelle Santella Mercurio 2.That my date of birth is: 11-1938. 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: 530 Plum Street Logansport, IN 46947 5.The following is a list of all my previous names: Maria del Carmen Isabel Mercurio (Maiden); Maria del Carmen Isabel Santella 6.That I do hold a valid United States passport. My proof that I am a United States citizen is Naturalization 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: NONE 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: I am divorced and want to go back to my maiden name. 12.That I wish to change my name to: Marycarmen I. Mercurio. 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 represenatations are true. /s/ Marycarmen I. Santella Mercurio 530 Plum Street Logansport, IN 46947 L-355 9/15 9/22 9/29 hspaxlp
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