On August 04, 2022 a
Complaint,Petition
was filed
involving a dispute between
Worth, Katherine Grace,
and
for Change of Name Managed
in the District Court of Worcester County.
Preview
Worcester Probate and Family Court
Date Filed: 8/4/2022 9:18 PM
Commonwealth of Massachusetts Case Number:
PETITION TO Docket No.
The Trial Court
CHANGE NAME OF ADULT Probate and Family Court
G. L. c. 210, § 12
In the Matter of:
Katherine Grace Worth Worcester Division
First Name Middle Name Last Name
(Current Name of Petitioner)
INFORMATION ABOUT THE PETITIONER
1. My current legal name is: Katherine Grace Worth
First Name Middle Name Last Name
2. My current address is: 104 dresser street Apt 2 southbridge MA 01550
(Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip)
Mailing Address, if different:
(Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip)
Primary Phone #: 7744029080 Email Address: bugworth02@gmail.com
FORM ALERT: The petitioner must reside in the county where this petition is filed.
3. Have you changed your name prior to this petition? No Yes
If Yes, please complete the following:
From:
To:
Reason:
FORM ALERT: A certified copy of your birth certificate and a certified copy of any prior name change (i.e., marriage
certificate, divorce decree, court order changing name) must be filed with this petition.
Check here to request a return, by first class mail, of all certified copies of documents filed with the court
after review and processing.
INFORMATION ABOUT THE PROPOSED NEW NAME
4. I am requesting that my name be changed from my current legal name to:
Bug Edward Worth
First Name Middle Name Last Name
5. I am requesting that my name be changed for the following reason:
This is my preferred name
AUTHORIZATION TO CONDUCT A CARI AND WMS CHECK
6. I authorize the court to conduct a Court Activity Record Information (CARI) and Warrant Management System (WMS)
check on any names used by me by submitting the attached Court Activity Record Information and Warrant Management
System Release Request Form (CJP 34).
CJP 27 (7/20/18) page 1 of 2
Worcester Probate and Family Court
OTHER REQUESTS (OPTIONAL) Date Filed: 8/4/2022 9:18 PM
Case Number:
7. If there is a hearing on this petition, I request an interpreter. Language:
→
NOTARIZED SIGNATURE OF PETITIONER
08/04/2022 Sign here in the presence of a Notary
Date:
Katherine Grace Worth
Type or Print Name of Petitioner
State Florida
xxxxxxxxxxxxxxxx
Commonwealth of Massachusetts
County of Pasco
On This 4th day of August , 20 22 , before me, the undersigned notary public, personally appeared
Katherine Grace Worth , proved to me through satisfactory evidence of identification, which
(Name of Document Signer)
were MA ID , to be the person who signed the preceding or attached document in my presence, and
who swore or affirmed to me that the contents of the document are truthful and accurate to the best of (his) (her) knowledge
and belief.
(seal) Notary Public Signature My commission expires: 10/01/2024
Print Name William R Scharff Jr
Notarial Act performed by Audio-Video Communication
Information on Attorney for Petitioner, if any
Signature of Attorney
(Print name)
(Address) (Apt, Unit, No. etc.)
(City/Town) (State) (Zip)
Primary Phone #:
B.B.O. #
Email:
CJP 27 (7/20/18) page 2 of 2
Document Filed Date
August 04, 2022
Case Filing Date
August 04, 2022
Category
Change of Name Managed
For full print and download access, please subscribe at https://www.trellis.law/.
Preview
Worcester Probate and Family Court Date Filed: 8/4/2022 9:18 PM Commonwealth of Massachusetts Case Number: PETITION TO Docket No. The Trial Court CHANGE NAME OF ADULT Probate and Family Court G. L. c. 210, § 12 In the Matter of: Katherine Grace Worth Worcester Division First Name Middle Name Last Name (Current Name of Petitioner) INFORMATION ABOUT THE PETITIONER 1. My current legal name is: Katherine Grace Worth First Name Middle Name Last Name 2. My current address is: 104 dresser street Apt 2 southbridge MA 01550 (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Mailing Address, if different: (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Primary Phone #: 7744029080 Email Address: bugworth02@gmail.com FORM ALERT: The petitioner must reside in the county where this petition is filed. 3. Have you changed your name prior to this petition? No Yes If Yes, please complete the following: From: To: Reason: FORM ALERT: A certified copy of your birth certificate and a certified copy of any prior name change (i.e., marriage certificate, divorce decree, court order changing name) must be filed with this petition. Check here to request a return, by first class mail, of all certified copies of documents filed with the court after review and processing. INFORMATION ABOUT THE PROPOSED NEW NAME 4. I am requesting that my name be changed from my current legal name to: Bug Edward Worth First Name Middle Name Last Name 5. I am requesting that my name be changed for the following reason: This is my preferred name AUTHORIZATION TO CONDUCT A CARI AND WMS CHECK 6. I authorize the court to conduct a Court Activity Record Information (CARI) and Warrant Management System (WMS) check on any names used by me by submitting the attached Court Activity Record Information and Warrant Management System Release Request Form (CJP 34). CJP 27 (7/20/18) page 1 of 2 Worcester Probate and Family Court OTHER REQUESTS (OPTIONAL) Date Filed: 8/4/2022 9:18 PM Case Number: 7. If there is a hearing on this petition, I request an interpreter. Language: → NOTARIZED SIGNATURE OF PETITIONER 08/04/2022 Sign here in the presence of a Notary Date: Katherine Grace Worth Type or Print Name of Petitioner State Florida xxxxxxxxxxxxxxxx Commonwealth of Massachusetts County of Pasco On This 4th day of August , 20 22 , before me, the undersigned notary public, personally appeared Katherine Grace Worth , proved to me through satisfactory evidence of identification, which (Name of Document Signer) were MA ID , to be the person who signed the preceding or attached document in my presence, and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of (his) (her) knowledge and belief. (seal) Notary Public Signature My commission expires: 10/01/2024 Print Name William R Scharff Jr Notarial Act performed by Audio-Video Communication Information on Attorney for Petitioner, if any Signature of Attorney (Print name) (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Primary Phone #: B.B.O. # Email: CJP 27 (7/20/18) page 2 of 2