STATE OF INDIANA
COUNTY OF KOSCIUSKO
CAUSE NO. 43C01-2406-MI-69
IN RE THE NAME CHANGE OF:
Javier Estrada Medina
Petitioner
VERIFIED PETITION FOR
CHANGE OF NAME
Petitioner, Javier Estrada Medina, pro se, respectfully petitions the court to
change name. In support of this Petition, Petitioner states as follows:
1. That my current name is Javier Estrada Medina.
2. That my date of birth is 11/12/1966.
4. That my mailing address is: 624 E. Acorn Dr., Warsaw, IN 46582.
6. That I do hold a valid United States passport. My proof that I am a United
States citizen is proof of citizenship. I will bring this document to my change of name
hearing for verification.
7. I do not have any 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 change of name 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
Indiana Code 11-8-8.
11. That I wish to change my name to: Javier Estrada.
12. That I request that the name on my birth certificate not be changed.
WHEREFORE, I respectfully request that this Court grant my Petition for Name
Change, and for all other just and proper relief. I affirm under penalties for perjury
that the foregoing representations are true.
Shannon L. Dick
Notary, Kosciusko County
