Name Change Affidavit Template

This Name Change Affidavit (the “Affidavit”) is made on [Date] by:

Affiant: [Full Name], date of birth: [DOB] (optional), address: [Address], phone/email: [Contact].

1. Current and Former Name

1.1 Former Legal Name: [Old Full Name]
1.2 Current Legal Name: [New Full Name]
1.3 Date Name Change Took Effect: [Date]

2. Basis for Name Change (Select One)

2.1 ☐ Court order (attach copy)
2.2 ☐ Marriage (attach marriage certificate)
2.3 ☐ Divorce (attach decree)
2.4 ☐ Adoption (attach order)
2.5 ☐ Other legal basis: [Explain + attach proof]

3. Purpose of This Affidavit

3.1 I am making this Affidavit to request that my records be updated with: ☐ bank ☐ employer ☐ school ☐ insurer ☐ government agency ☐ other: [List].

4. Identification and Supporting Documents

4.1 The following documents are attached or available upon request:
☐ Court order/certificate
☐ Marriage certificate
☐ Divorce decree
☐ Updated government ID
☐ Social Security/Tax ID update confirmation (if applicable)
☐ Other: [List]

5. Statement Under Oath

5.1 I declare under penalty of perjury that the statements in this Affidavit are true and correct to the best of my knowledge.

Signatures

Affiant: [Full Name]
Date: [Date]
Signature: ___________________________

Witnesses (If Required)

Witness Name: [Name]
Date: [Date]
Signature: ___________________________

Notary / Notarization (If Required)

State of [State]
County of [County]

On [Date], before me, [Notary Name], personally appeared [Affiant Full Name], known to me (or satisfactorily proven) to be the person whose name is subscribed to this Affidavit, and acknowledged that they executed it for the purposes stated.

Notary Public Signature: _______________________
My Commission Expires: _______________________
Notary Seal (if applicable): ___________________