Affidavit

I, (legibly print the old name)________________________________________,
request a change of name as it shall appear henceforth on my official records at Western Michigan University to 

(legibly print the new name )________________________________________ .

I hereby swear that this change in name has not been requested for any fraudulent purpose. I am also aware that the change will affect only those records compiled from this date onward. 

My Western Identifcation Number (WIN) is _ _ _ _ _ _ _ _ _ _ 

Check here if you have applied for graduation and are requesting this name change for your diploma.

The following needs to be signed in the presence of a Notary Public:

_____________________________________ signature 

_____________________________________ date 

County of _________________________ 

State of __________________________ 

Sworn and subscribed to before me this ___ day of ______, 200__ 

___________________________________________ 
(Notary Public)