For Clerk’s Use Only Name of Person Filing: ____________________________________ Mailing Address: ____________________________________ City, State, Zip Code: ____________________________________ Daytime/Evening Phone Number: ____________________________________ ATLAS Number (if applicable) ____________________________________ Attorney Bar Number (if applicable) ____________________________________ Represented by Self or by Attorney . SUPERIOR COURT OF ARIZONA IN MOHAVE COUNTY Case Number: __________________________ APPLICATION FOR CHANGE OF NAME FOR A FAMILY In the Matter of: _________________________________ Applicant STATEMENTS TO THE COURT, UNDER OATH OR AFFIRMATION 1. INFORMATION ABOUT PERSONS FOR WHOM NAME CHANGE IS REQUESTED A. Name on Birth Certificate (Applicant) or Current Legal Name _________________________ _________________________ _________________________ (First) (Middle) (Last) Applicant’s Address:______________________________________________________________________ County of Residence:__________________________________ Date of Birth:_________________________ Place of Birth:_______________________________________ (Month / Day / Year) (City / State / Nation) REQUEST NAME BE CHANGED TO: _________________________ _________________________ _________________________ (First) (Middle) (Last) B. Name on Birth Certificate or Current Legal Name: _________________________ _________________________ _________________________ (First) (Middle) (Last) Address Same as applicant, or:_________________________________________________________ Relationship to Applicant:________________________ County of Residence: _______________________ Date of birth: _____________________ Place of Birth: ______________________________________ (Month / Day / Year) (City / State / Nation) REQUEST NAME BE CHANGED TO: _________________________ _________________________ _________________________ (First) (Middle) (Last) 11/01/2006 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Case No.________________ C. Name on Birth Certificate or Current Legal Name: _________________________ _________________________ _________________________ (First) (Middle) (Last) Address Same as applicant, or:_________________________________________________________ Relationship to Applicant:________________________ County of Residence: _______________________ Date of birth: _____________________ Place of Birth: ______________________________________ (Month / Day / Year) (City / State, Nation) REQUEST NAME BE CHANGED TO: _________________________ _________________________ _________________________ (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 it appears on the birth certificate, address, date of birth, county of residence, place of birth, relationship to Applicant, and the new name requested. 3. REASON FOR THIS REQUEST FOR CHANGE OF LEGAL NAME I request that the legal names be changed as listed above for the following reasons: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 4. ADDITIONAL STATEMENTS A. Has any person listed above been convicted of a felony? Yes No If yes, who? _____________________________________________________________ B. This application is made solely for the best interest of the persons named above. It will not release the persons from any obligations incurred or harm any rights of property or action in any original name. OATH OR AFFIRMATION STATE OF ARIZONA ) ) ss. COUNTY OF MOHAVE ) The contents of this document are true and correct to the best of my knowledge and belief. Signature:______________________________________ Date:____________________________ Sworn to or affirmed before me on this __________________ day of _________________, 20_____________ By: ______________________________________ My Commission Expires:_____________________ 11/01/2006 ______________________________________ Notary Public or Deputy Clerk Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com