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 USE ONLY Respondent SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY Case Number: In the Matter of: APPLICATION FOR CHANGE OF NAME FOR A MINOR CHILD (ARS 12-601) A Minor STATEMENTS TO THE COURT, UNDER OATH OR AFFIRMATION 1. INFORMATION ABOUT ME, THE APPLICANT (First) (Middle) (Last) Applicant's Address is Listed Above. Date of Birth: (Month / Day / Year) County of Residence: Place of Birth: (City, State, Nation) 2. INFORMATION ABOUT THE MINOR FOR WHOM THIS NAME CHANGE IS REQUESTED: Name as it appears on the Birth Certificate: (First) Address Same as Applicant, or: Relation to Applicant: © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED (Middle) (Last) County of Residence: CVNCM11f 050115 Use current version American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 Case No. Date of Birth: (Month / Day / Year) Place of Birth: (City, State, Nation) New Name Requested: (First) (Middle) (Last) 3. 4. I ASK THAT THE BIRTH RECORDS BE CHANGED TO REFLECT THE NEW NAME LISTED ABOVE. I REQUEST THAT THE NAME BE CHANGED FOR THE FOLLOWING REASONS: ADDITIONAL STATEMENTS I understand that this name change does not establish paternity and will not cause a father's name to be added to a birth certificate. This application is made solely for the best interest of the minor child named above. It will not release the person from any obligations incurred or harm any rights of property or action in any original name. 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 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CVNCM11f 050115 Use current version