NOTICE OF PETITION FOR CHANGE OF NAME STATE OF INDIANA SS COUNTY OF KOSCIUSKO IN RE THE NAME CHANGE OF SAMIE DEE BLACK, Petitioner IN THE KOSCIUSKO CIRCUIT COURT CAUSE NO. 43C01-1206-MI-72 Samie Dee Black, whose mailing address is: PO Box 716, North Webster, IN 46555 And, if different, my address is: 811 South Main Street, North Webster, IN 46555. Kosciusko County, Indiana hereby gives notice that she/she has filed a petition in the Kosciusko Circuit Court requesting that his/her name be changed to Samie Dee Hine. Notice is further given that hearing will be held on said Petition on the 17th day of August, 2012 at 9:30 o'clock a.m. Samie Dee Black, petitioner Date: June 21, 2012 Jason McSherry, Kosciusko Circuit Court Clerk j25, j2,9
