IN THE CIRCUIT COURT OF {COUNTY NAME} COUNTY, MISSOURI

JOHN DOE, by his next friend,
JANE JONES	)
{STREET ADDRESS]	)
{CITY}, MO  {ZIP},	)
	)
	)	CASE NO. ____________________
	)
PETITIONER.	)

	FATHER’S CONSENT TO CHANGE OF NAME
I, JAMES DOE, hereby consent to JOHN DOE, my minor child, to his change of name to JOHN JONES.

____________________________________
JAMES DOE

DATED:____________________________

STATE OF MISSOURI	)
) ss.
COUNTY OF __________	)

On this ____ day of _____________, 2009, before me personally appeared JAMES DOE, to me known to be the person described in and who executed the foregoing instrument, and acknowledged that he executed the same as his free act and deed. 

IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my official seal in {city name}, Missouri, the day and year first above written.

My Commission Expires:  __________________.

__________________________________
Notary Public