Wiley STATE OF INDIANA SS: COUNTY OF DECATUR IN THE DECATUR CIRCUIT COURT CASE NO: 16C01-1605-MI-198 IN RE CHANGE OF NAME OF MINOR: JAX MARKUS WILEY ERIN DAWN PEETZ Petitioner. VERIFIED PETITION FOR CHANGE OF NAME OF MINOR Petitioner, Erin Dawn Peetz, pro se, respectfully petitions this court to change the name of the above-noted child. In support of this Petition, Petitioner states as follows: 1.Petitioner is the mother of the child whose name is sought to be changed. 2.The written consent of the non-petitioning parent or guardian for the name change of the minor child is filed with this Petition. 3.That the child's name is JAX MARKUS WILEY. 4.That the child's date of birth is 1-2015. 5.That the child's mailing address is: 1646 N Nieman Dr Greensburg, IN 47240 6.That I will bring the child's Indiana Identification card to the Change of Name Hearing for Verification. 7.The following is a list of all the previous names of the child: N/A 8.That the child does not hold a valid United States passport. Proof that the child is a United States citizen is Social Security Card. I will bring this document to the Change of Name Hearing for verification. 9.That the following judgments of criminal conviction of a felony under the laws of any state or the United States have been entered against the child, or I have stated immediately below that the child does not have any felony convictions: N/A 10.That changing the child's name is not an effort to defraud any of the child's creditors. 11.That notice of the request for name change has been published in a local publication as required by law and will be brought to the Change of Name Hearing. 12.That the child is not confined to a Department of Correction facility or a sex or violent offender who is required to register under I.C. 11-8-4. 13.That pursuant to Indiana Code 34-28-2-1, I petition this court to change the child's name. Pursuant to Indiana Code 34-28-2-2(b), the reason the change of the child's name is requested is: middle name was after his grandfather who has now chosen not to be in his life. 14.That I request that the child's name be changed to JAX JOSEPH WILEY. 15.The non-petitioning parent or guardian of the Minor child has been served with a copy of this Petition as required by the Indiana Trial rules. 16.I request this Court to set a hearing to consider the Petition for Change of Name of Minor Child. WHEREFORE, I respectfully request that this Court grant this Petition for Name Change of a Minor, and for all other just and proper relief. I affirm under the penalties of perjury that the foregoing representations are true. /s/ Erin D. Peetz, Petitioner GDN-275 9/13 9/20 9/27 hspaxlp
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