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Adult Name Change Clinic Application
Contact Information
Citizenship: I am a...
*
US Citizen
Non-citizen
Current Legal Name (to change)
*
First Name
Middle Name
Last Name
Suffix
Full Chosen Name (new name requested)
*
First Name
Middle Name
Last Name
Suffix
List all former names or aliases (i.e., maiden name or other married names)
Date of Birth
*
Last four digits of Social Security Number
*
Provide the address where you live. If you are homeless, provide an address where you spend most of your time.
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is this a safe address to receive mail?
Yes
No
Email Address
*
example@example.com
Is this a safe email for Legal Aid to use?
Yes
No
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
May we text you on this phone?
Yes
No
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Demographic Information
Gender
*
Male
Female
Prefer not to say
Nonbinary
Self-Describe
If you prefer to self-describe, you may identify your gender here:
Pronouns
She/Her
He/Him
They/Them
Self-Describe
Prefer not to say
If you prefer to self-describe, you may identify your pronouns here:
Ethnicity
*
American Indian or Alaskan Native
Asian
Black or African American
Hispanic, Latino, or Spanish
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White/Caucasian
Some other race, ethnicity, or origin
Two or more races
Not Listed or Unknown
Are you eligible or enrolled in a Native American tribe?
*
Yes
No
I don't know
If yes, which Tribe?
Please Select
Iowa Tribe of Kansas and Nebraska eligible
Iowa Tribe of Kansas and Nebraska enrolled
Oglala Sioux eligible
Oglala Sioux enrolled
Omaha eligible
Omaha enrolled
Ponca eligible
Ponca enrolled
Rosebud Sioux eligible
Rosebud Sioux enrolled
Sac and Fox eligible
Sac and Fox enrolled
Santee Sioux eligible
Santee Sioux enrolled
Winnebago eligible
Winnebago enrolled
Other tribe eligible
Other tribe enrolled
Do you need an interpreter?
*
Yes
No
If yes, which language?
Have you ever served in the military, including the Reserves, National Guard, Army, Navy, Air Force, Marines, or Coast Guard?
*
Yes
No
Do you have a disability or cognitive impairment?
*
Physical disability (such as mobility, vision, hearing)
Cognitive impairment (such as problems with memory or understanding)
Mental health disability
Other
None
Are you a victim of abuse?
*
Yes
No
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Household and Financial Information
What is your marital status?
*
Single
Married
Divorced
Widowed
Separated
Group
Domestic Partner
Other
In your household, how many adults are aged 19 or over (including yourself)?
*
How many children live in the house full time?
*
Do you have income from employment?
*
Yes
No
Hours per week
Wages per hour
Does anyone else in your household have income from employment?
Yes
No
Hours per week
Wages per hour
Do you or anyone in your household have any additional income from employment (like a second job or part-time job)?
Yes
No
Hours per week
Wages per hour
Do you have any of the following types of income? (Select all that apply)
Social Security (SSI)
Social Security Disability Insurance (SSDI)
Social Security Survivors Benefit
Veteran's Benefits
Pension/Retirement (IRA/401K)
Trust/Interest/Div
Unemployment Insurance
State Stipend
Adoption Stiped
Foster Care Stipend
TANF/ADC
Child Support
Alimony
Student Loans
Workmens Comp
Other General Assistance
Other
What is your monthly income from the income type(s) you selected above?
Do you expect your income to change within the next 90 days?
Yes
No
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Household and Financial Information (continued)
What is your monthly rent or mortgage amount?
Does your household have any of the following expenses listed on the dropdown below? Please include all monthly expenses that apply.
*
What is the approximate value of your personal property in your house (furniture, clothes, electronics, jewelry, etc.)? For instance, if you had a garage sale to sell all of the personal belongings inside your home, how much money do you think you would get for everything? (Do *not* include value of the house or any vehicles.)
Do you have any checking accounts?
*
Yes
No
If yes, how much is in the account?
Do you have any savings accounts?
*
Yes
No
If yes, how much is in the account?
Do you have another type of bank account, such as a Certificate of Deposit (COD)?
*
Yes
No
If yes, how much is in the account?
Do you or anyone in your household own a vehicle used daily for transportation?
*
Yes
No
What is the estimated value of that vehicle?
Do you or anyone in your household own any additional vehicles?
*
Yes
No
What is the estimated value of that vehicle?
Do you or anyone in your household own any real estate (such as a house or land)?
*
Yes
No
What is the estimated value of real estate?
Do you or anyone in your household have a retirement account such as an IRA/401k/403b?
*
Yes
No
What is the estimated value?
What is your housing situation?
*
Rent: Private landlord
Rent: Public housing
Rent: Housing voucher/subsidized/Section 8
Rent: Other rental assistance (GA, Regional, etc)
Own: Real property
Own: Mobile home
Own: Condo/Townhome/Co-op
Homeless
Other (including assisted living, long-term care)
Are you at risk of losing your housing?
Yes
No
How did you hear about the clinic?
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Name Change Eligibility Information
Will you be at least nineteen (19) years old on September 19, 2026?
*
Yes
No
If you will be younger than nineteen (19) years old on September 19, 2026, are you either emancipated by court order or married?
*
Yes
No
N/A
Are you applying to change your own name?
*
Yes
No
Do you currently reside in Douglas County, Nebraska?
*
Yes
No
Have you been a resident of Douglas County for at least one year by September 19, 2026?
*
Yes
No
To change your name, the law requires you to publish public notice of your name change in a Douglas County newspaper. Would this public notice requirement cause you any risk of harm or danger if a particular person finds out about your name change?
*
Yes
No
Would publishing your current address cause you any risk of harm or danger if a particular person finds out where you are living?
*
Yes
No
If you answered "Yes" above, please tell us why you believe publishing the notice of Name Change and/or your address may endanger you so that we may discuss your options.
The court costs of an Adult Name Change are $199.00 ($144.00 Filing fee + $55.00 publication fee). Legal Aid provides financial assistance with these fees and can assist anyone with a limited income to file a fee waiver application asking the judge to waive your court fees. Do you believe you may be eligible for a fee waiver based on having a limited income?
*
Yes
No
Continue Later
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