PROBATE COURT OF LUCAS COUNTY, OHIO JACK R. PUFFENBERGER, JUDGE IN RE: CHANGE OF NAME OF (Name Requested) (Present Name) _ _______________ TO___________________________________________________________________ CASE NO. ________________ APPLICATION FOR CHANGE OF NAME OF MINOR [R.C. 2717.01] The applicant states that the applicant is the parent legal guardian guardian ad litem of the minor and that the minor has been a bona fide resident of ________________ County, Ohio, for at least one year immediately prior to the filing of this application. A certified copy of the minor's birth certificate is attached. The applicant states that the name and address of Parent 1 of the minor is: Name ____________________________________________________ ____________________________________________________ ____________________________________________________ Zip Address City and the name and address of Parent 2 or alleged father of the minor is: _______________________________________________________ _______________________________________________________ _______________________________________________________ City Zip Address Name Applicant states that the address of Parent 1 Parent 2 or alleged father is unknown and cannot with reasonable diligence be ascertained. There is no person alleged to be the father of the minor. The applicant states that the person for whom a change of name is being requested 1)_________ Initials 2) ________ Initials has has not been convicted of, pleaded guilty to, or been adjudicated a delinquent child for identity fraud. has a has no duty to comply with R.C. 2950.04 or R.C. 2950.041 because the applicant was convicted of, pled guilty to, or was adjudicated a delinquent child for having committed a sexually oriented offense or a child-victim oriented offense. FORM 21.2 ­ APPLICATION FOR CHANGE OF NAME OF MINOR Amended: March 15, 2016 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Reverse of Form 21.2] CASE NO. ____________________ The applicant requests a change of name of the minor from __________________________________ to __________________________________________________________________________________ for the following reason: ________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ The applicant states that the applicant will cause notice of the application to be published once in a newspaper of general circulation in this county at least thirty (30) days before the hearing on this application. In addition, notice will be given by the applicant to any non-consenting parent or alleged parent, whose addresses are known, by certified mail, return receipt requested. _________________________________________ Attorney for Applicant _________________________________________ Typed or Printed Name _________________________________________ Address _________________________________________ City State Zip _________________________________________ Telephone Number (include area code) Attorney Registration No. _____________________ ______________________________________ Applicant's Signature ______________________________________ Typed or Printed Name ______________________________________ Address ______________________________________ City State Zip ______________________________________ Telephone Number (include area code) JOURNAL ENTRY SETTING HEARING AND ORDERING NOTICE The Court orders this application set for hearing on the ______ day of _____________________, _________, at ______________ o'clock _____.m. The applicant is ordered to cause notice of the application to be given by one publication in a newspaper of general circulation in this county at least thirty (30) days prior to the hearing date, as well as certified mail service, return receipt requested, if necessary, as required by law. ______________________________________ Judge Jack R. Puffenberger By: ______________________________________ Deputy Clerk FORM 21.2 ­ APPLICATION FOR CHANGE OF NAME OF MINOR Amended: March 15, 2016 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com