IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Change of Name of , a Minor Child (current legal name) by: Petitioner (parent or legal guardian) , ) ) ) ) ) ) ) ) ) CASE NO. PARENTAL CONSENT FROM NON-PETITIONING PARENT CI I, , am the legal mother father of the minor child named above. I give my consent to the child being given the new name of . I understand that this name change does not change any of my rights or responsibilities as parent of this child. I further understand that after the name change has been ordered by the court, the child will be known by the new name for all legal purposes and my consent may not be withdrawn. I waive notice of all further proceedings in this case. Signature Printed Name Mailing Address City State Daytime Telephone Subscribed and sworn to or affirmed before me at on . (date) , Alaska ZIP (SEAL) CIV-695 (7/11)(cs) PARENTAL CONSENT Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: Civil Rule 84(e) AS 09.55.010 American LegalNet, Inc. www.FormsWorkFlow.com