Petition Name ChangeCal. Super. - 6th Dist.May 3, 2021NC-ZOO ATTORNEY OR PARTY WITI'DUI' ATI’ORNEY STATEBMNMER; Wzmssandm MichMIe. Forwx WWE ?> h m Lm Hp? $5amEE‘rADDRESS: I320 ran Q ’ . ”TY: San jose, STATE: cgq mecca 451$ FE LEE :flfmfiFO:('Mgegte< t_Foan@qMol.I. com MAY 0 3 2021 SUPERIOR COURT 0F CALIFORNIA, couu'rv 0F S a n ’rq Harm. Supefiggrk “29 310523; cumsszr ADDRESS: 19 fl. NO V‘kh F‘I ”31" 5 ‘H’QQ " B é DEPUTY MAILING ADDRESS: Lg V CITYANDZPCODE: San Iogel q9[{ g BRANCH NAME: PErmON 0F (name): Cassa ndm Hicwte Eon: n PETITION FOR CHANGE 0F NAME, RECOGNITION 0F CHANGE 0F “SEWER GENDER, AND ISSUANCE OF NEW BIRTH CERTIFICATE Before you comfileta thls petition, ou should read the Instructions forFilin on the next page. You must answer all questions and c eck all boxes th apply to you on this petition. You must e this petltlon In the superior court of tho county where the person whose name is to be changed resides. 1. Petitioner (pmsantnams): Ca SS and (a M; che [ [e‘ F0 r Hn ls 18 years old or older and a resldent of this county. 2. Petitioner requests that the court decree that petitioner’s name is changed. In order to conform to petitioner's gender Identity, to (”wpmmm)‘ Tulian Cod Forlrm 3. Petitioner requesm a decree recogniflng that the petitioner's gender is changed to: a. m female. b. male. c. E nonblnary. 4. Petitioner requests that the court order that a new binh cerfifiwte be issued reflecting the gender and name changes sought by this petition. 5. Petitioner requests mat the court issua an order directing any interested persons to file written objecflons to show cause why the petition for change of name should not be granted. 6. Petitioner provides the following information In support of this petition: a. The declarafion below. b-f. The infon'nafion contained In the attachment (attach a completed copy ofthe attachment Name and Information Aboutthe Person Whose Name ls to Be Changed (form NC-110)). DECLARATION I(present name): declare under penalty of perjury under the laws of the state of California that the requestfor a change in gender to (check one)D femaleE male E nonbinary is to confonn my legal genderto my gender identity and is not for any fraudulent purpose. Date: Cassandra Micmua, Forkn } (TYPE OR PRINT NAME OF PEHTIONER) y (SIGNATURE OF PETITIONER) 0an on next page) P0991 012 mmwfvgfmmm PETITION FOR CHANGE 0F NAME. RECOGNITION 0F cHANsE Hmmggg;mggmfigm Hc-zoo [Ramsmambartzms] OF GENDER, AND ISSUANCE OF NEW BIRTH CERTIFICATE mmmmoov Cassandra Michelle Fortin NC-1 10 PETITION OF (Name ofpefib'oner or petitioners): msa NUMBER; Caseandrd MIChQHQ EOY’fln FORCHANGEOFNAME NAME AND INFORMATION ABOUT THE PERSON WHOSE NAME [S TO BE CHANGED Attachment 1 of l Attachment to Petition (form NC-100, form NC-ZOO, or form NC-SOO) {You must use a separate attachment for each person whose name is to be changed. lfpetitioneris a guardian of a minor, a supplemental attachment, Declaration of Guardian (form NC-H OG), must aiso be completed and attached for each minor whose name is to be changed.) 7. (Continued) Petitioner applies for a decree to change the name of the following person: b. Self Other ~ - ?Present r9116 (specify): Cassandra MICKQH L FOV \Wfl (2) Proposed name (specify): I91“ an CC“ F0 (1' n (3) Born on (date ofbirth): q I l 5 l quq and presently E under 18 years ofage fl over 18 years of age (4) Bom at (place ofbirth): CA j San SO $6 (5) Sex {as stated on on'ginalbirth certificate): E Male Female (6) Current residence address (street. city, county, and zip code): r520 Branhana Ln,Apr 33,8an3bse.ffl q<”8 c‘ Reason for name change (explain): @21er r ma fch For mu id em".M d. Relationship ofthe petitioner to the person whose name will be changed: (1) E self (4) E nearrelafive (indicate reiafionship): (2) E parent (5) m Other(specify): (3) E guardian e. If the person whose name will be changed is under 18 years of age. provide the names and addresses. ifknown, of the following persons: (1) Parent (name): (address): (2) Parent (name): (address): (3) (Only if neither parent is living) Near relatives (names, refationships, and addresses): f. lfthe person whose name will be changed is 18 years of age or older, that person must sign the following declaration: DECLARATION l declare under penalty of pen‘ury under the raws of the State of California that (check one)E | am not E I am under the jurisdiction of the California Department of Corrections and Rehabilitation (in state prison or on parole) or In county jail and (check one) E | am not C] l am required to register as a sex offender under Penal Code section 290. Date: é) cassand ra Mzmeut For rm } mPE 0R palm NAME 0F PERSON WHOSE NAME Is To BE CHANGED; (Slew: o: pERsou WHOSE NAME Is To BE CHANGED) (”petitioner ls represented by an attomey, the atromey’s signature follows): Date: D A(TYPE OR PRINT NAME) 7 (SIGNATURE OFATI'ORNEY) (Each petitioner must sign this petition in the space provided below or, if additional pages are attached, at the end of the last attachment.) l dedare under penalty of perjury under the laws of the State of California that the information in the foregoing petition is true and correct] Z I CassandWfl @or¥:n } j) (WPE 0R PRINT NAME) MATURE 0F PErmd'NER) Date: mPE 0R PRINT NAME} (5:6NATURE 0F PETrrIONER) | ADD ADDmOHAL SIGNATURE LINES FOR ADDmONAL PETmONERs | | SIGNATURE 0F PETmONERs Fouows LAST ATTACHMENT pas, 1 o“ an Adopted for Mandatory Use ATTACHMENT TO Code of CM] Procedure, 5 1275 el seq www.courtsmgov ififféfnfflé’lgfiifim PETITION FOR CHANGE 0F NAME
