PETITION FOR CHANGE OF NAME OF A MINOR

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF CLACKAMAS Probate Department CASE NO. 20CV45579 PETITION FOR CHANGE OF NAME OF A MINOR In the Matter of the Name Change of: (PRINT Present Name of Minor Child) Khloe Bell Stokes From the Above Name to: Khloe Bell Workman (PRINT Proposed New Name of Minor Child) Nicholas Wise obo DHS (PRINT Full Name of Proposed Guardian Ad Litem) Petitioner alleges: 1. The following is my contact information as Petitioner: Name: Nicholas Wise Address: 315 S. Beavercreek Rd. Oregon City, OR. 97045 Phone number(s): 971-673-7223 E-mail: nicholas.k.wise@dhsoha.state.or.us 2. I am the caseworker of the minor named in this petition and I am at least 18 years old. Department of Human Services is already the legal guardian for the minor in this proceeding. 3. The birth name, date of birth and place of birth of the minor are: Birth name: Khloe Bell Stokes Place of birth: May 23rd, 2013 Place of birth: Oregon City, Oregon 4. The currently residence address of the minor is: c/o Oregon City DHS, 315 S. Beavercreek Rd. Oregon City, OR 97045 and this is located within Clackamas County, Oregon. 5. The minor DOES now have a court-appointed Guardian. If there is a Guardian, the name, mailing address of the Guardian is: Same as the petitioner above, juvenile court judgment attached. 6. Both parents of the minor are living and the name, address, phone number and email address of the parents are as follows: Mother: Kristin Lee Stokes no known address Father: Christopher Richard Roebuck 400 S. 9th St. Richmond, IN. 47374 7. Is paternity established: YES Does the father’s name appear on the birth certificate? YES Has there ever been a court case involving paternity? NO 8. I am requesting this name change because: See attached form from DHS I hereby declare that the above statements are true to the best of my knowledge and belief. I understand they are made for use as evidence in court and are subject to penalty for perjury. Date: Dec. 11, 2020. /s/ Nicholas Wise Petitioner’s Signature Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the document you are filing with the court. DHS is represented by Oregon Department of Justice and the assigned AAG assisted in the completion of these documents. Submitted by: Julia Hyde OSB #130448 100 Market Street Portland, Oregon 97201 971-673-1880 Published Feb. 23, Mar. 2, 9 & 16, 2021. BT192624

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