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.	)

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

____________________________________
JANE JONES

DATED:____________________________

STATE OF MISSOURI	)
) ss.
COUNTY OF _________	)

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

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

My Commission Expires:  __________________.

__________________________________
Notary Public