Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: Lawyer's Bar Number: Representing Self, without a Lawyer or Attorney for Petitioner OR For Clerk's Use Only Respondent SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY Case Number: In the Matter of: APPLICATION FOR CHANGE OF NAME FOR A FAMILY (ARS 12-601) Applicant STATEMENTS TO THE COURT, UNDER OATH OR AFFIRMATION 1. INFORMATION ABOUT PERSON(S) FOR WHOM NAME CHANGE IS REQUESTED A. Name on Birth Certificate (Applicant) or Current Legal Name: (First) (Applicant's Address is Listed above) Date of Birth: (Month / Day / Year) REQUESTS NAME BE CHANGED TO: (First) (Middle) County of Residence: Place of Birth: (Last) (City, State, Nation) (Middle) (Last) © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CVNCF11f 050115 Use current version Case No. B. Name on Birth Certificate or Current Legal Name: (First) Address Same as Applicant, or: (Middle) (Last) Relation to Applicant: Date of Birth: (Month / Day / Year) County of Residence: Place of Birth: (City, State, Nation) REQUESTS NAME BE CHANGED TO: (First) (Middle) (Last) C. Name on Birth Certificate or Current Legal Name: (First) Address Same as Applicant, or: Relation to Applicant: (Middle) (Last) County of Residence: Date of Birth: (Month / Day / Year) REQUESTS NAME BE CHANGED TO: Place of Birth: (City, State, Nation) (First) (Middle) (Last) If you wish to include more people in this application, please attach another sheet of paper. List for each person their current name as on birth certificate, address, date of birth, county of residence, place of birth, relationship to Applicant, and the new name requested. © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CVNCF11f 050115 Use current version Case No. 2. REASON FOR THIS REQUEST FOR CHANGE OF LEGAL NAME I request that the legal names be changed as listed above for the following reasons: 3. STATEMENTS TO THE COURT REQUIRED BY ARIZONA LAW (A.R.S. § 12-601(C)) (Check the boxes that indicate a true statement.) a. I submit this application solely for the benefit and in the best interests of the persons for whom the name change is requested. I understand and acknowledge that this change of name, if granted, will not release me or anyone for whom a change of name is requested on this Application from any obligations incurred or harm any rights of property or action in any previous name. 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. Have you or any adult listed above ever been convicted of a felony? If "Yes" to "d", all felony convictions are listed below. b. c. d. Yes No Name of Person Convicted 1 2 3 4 5 6 Case No. County & State Sentence Date of Conviction Additional convictions are listed on attached page in the same format as above. Is there anything regarding your felony conviction(s) that you would like to bring to the Court's attention? (Optional) © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CVNCF11f 050115 Use current version Case No. e. Are there any criminal charges (felony or misdemeanor) pending against you or anyone listed on this Application for Name Change at this time? Yes No List all pending charges below Name of Person with Pending Charges 1 2 3 4 5 6 Name of Court or City & State Case No. Is there anything regarding your pending criminal charges that you would like to bring to the Court's attention? (Optional) UNDER OATH OR BY AFFIRMATION I swear or affirm under penalty of perjury that the contents of this document are true and correct to the best of my knowledge and belief. Date Petitioner's Signature Printed Name STATE OF COUNTY OF Subscribed and sworn to or affirmed before me this: (date) . by (notary seal) Deputy Clerk or Notary Public © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CVNCF11f 050115 Use current version