Name of Person Filing: Street Address: City, State, Zip Code: Telephone Number: Representing Self (No Attorney), or If Attorney, Bar Number: Represented by Attorney For Clerk’s Use Only SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY In the Matter of Case Number: CV APPLICATION FOR CHANGE OF NAME FOR AN ADULT Current Name of Applicant (A.R.S. § 12-601) UNDER PENALTY OF PERJURY 1. INFORMATION ABOUT ME, THE APPLICANT: Name on Birth Certificate: or Current Legal Name: First Middle Last Date of Birth: Place of Birth: County of Residence: 2. REQUESTS TO THE COURT: I ask that my name be changed to: First Middle Last I ask that the birth records be ordered changed to reflect the new name listed above. 3. STATEMENTS TO THE COURT REQUIRED BY ARIZONA LAW (A.R.S. § 12-601(C)) (Check the boxes that indicate a true statement.) (For “d”, explain.) a. I submit this application solely for the benefit and in the best interests of the person for whom the name change is requested. b. I understand and acknowledge that this change of name, if granted, will not release me from any obligations incurred or harm any rights of property or action in any previous name. c. I am not knowingly requesting this change of name to that of another individual for the purpose of committing or furthering any offense of theft, forgery, fraud, perjury, organized crime or terrorism or any other offense involving false statements. d. I request this name change because: (Explain) © Superior Court of Arizona in Maricopa County September 2, 2008 ALL RIGHTS RESERVED Page 1 of 2 CVNC11f Use current version American LegalNet, Inc. www.FormsWorkflow.com Case No. e. Have you ever been convicted of a felony? Yes No If “Yes” to “e”, all felony convictions are listed below. Felony Case No. County & State Sentence Date of Conviction 1 2 3 4 5 Is there anything regarding your felony conviction(s) that you would like to bring to the Court’s attention? (Optional) f. Are there any criminal charges (felony or misdemeanor) pending against you at this time? Yes No If “Yes” to “f”, all pending charges are listed below: Pending Charges Name of Court or City & State Case No. 1 2 3 4 5 Is there anything regarding your pending criminal charges that you would like to bring to the Court’s attention? (Optional) OATH OR AFFIRMATION OF APPLICANT I affirm under penalty of perjury the information provided on this document is true and correct. Date Signature Signed & Affirmed before me this date: Date (Seal/My Commission Expires) Deputy Clerk or Notary Public © Superior Court of Arizona in Maricopa County September 2, 2008 ALL RIGHTS RESERVED Page 2 of 2 CVNC11f Use current version American LegalNet, Inc. www.FormsWorkflow.com