Election To Resume Maiden Name

In the Court of Common Pleas of Lancaster County, Pennsylvania __________________________________ __________________________________ VS __________________________________ __________________________________ To the Prothonotary of Lancaster County, Pennsylvania: It is my intention and I elect to resume my Maiden Name / Prior Name of __________________ _______________________________, having filed a Divorce Action on __________________ or having been divorced from _________________________________ in the Court of Common Pleas of Lancaster County, Pennsylvania, on _____________________________. Case Term & Number _________________ _______________________________________ Married Name _______________________________________ Elected Name State of Pennsylvania County of Lancaster On this, the ______________ day of _________________, 20____; before me Prothonotary the undersigned officer, personally appeared ____________________________________________ known to me (or satisfactorily proven) to be the person whose name ______________________ ________________________ subscribed to the within instrument, and acknowledged that she/he executed the same for the purposes therein contained. In Witness Whereof, I hereunto set my hand and official seal. _______________________________________ Prothonotary American LegalNet, Inc. www.FormsWorkflow.com