FOR CLERK USE ONLY Person Filing Document: ____________________________________ Mailing Address: ____________________________________ City, State, Zip Code: ____________________________________ Daytime/Evening Phone Number: ____________________________________ ATLAS Number (if applicable): ____________________________________ Attorney Bar Number (if applicable): __________________________________ Self or Represented by by Attorney SUPERIOR COURT OF ARIZONA IN MOHAVE COUNTY Case Number: ________________________ In the Matter of: APPLICATION FOR CHANGE OF NAME FOR A MINOR CHILD (A.R.S. �12-601) A Minor STATEMENTS TO THE COURT, UNDER OATH OR AFFIRMATION 1. INFORMATION ABOUT ME, THE APPLICANT _____________________________ (First) ________________________ _________________________________ (Middle) (Last) Applicant's Address:______________________________________________________________________ County of Residence:__________________________________ Date of Birth:___________________ Place of Birth: ____________________________________________ (Month / Day / Year) (City / State / Nation) 2. INFORMATION ABOUT THE MINOR FOR WHOM THIS NAME CHANGE IS REQUESTED: Name as it appears on the Birth Certificate: _____________________________ (First) ________________________ __________________________________ (Middle) (Last) Address Same as Applicant, or____________________________________________________ Relation to Applicant:_______________________ County of Residence:____________________________ Date of Birth:___________________ Place of Birth:_______________________________________________ (Month / Day / Year) (City / State / Nation) New Name Requested: _____________________________ (First) 3. ________________________ __________________________________ (Middle) (Last) I ASK THAT THE BIRTH RECORDS BE CHANGED TO REFLECT THE NEW NAME LISTED ABOVE. Revised: 4/13/2011 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case No._____________________________ 4. 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. OATH OR AFFIRMATION OF APPLICANT STATE OF ARIZONA ) ) ss COUNTY OF MOHAVE ) I affirm under penalty of perjury 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: ___________________ ____________________________________ Notary Public or Deputy Clerk Revised: 4/13/2011 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com