THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) CONSENT TO MINOR NAME CHANGE I, Print name , as parent guardian of the minor child, consent to change the child's name from (First, middle, last name) to (First, middle, last name) Dated Signature of person consenting to name change Mailing Address State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any , County of by Signature of Notarial Officer / Title NHJB-2322-F (10/30/2006) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com