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 FOR CLERK USE ONLY SUPERIOR COURT OF ARIZONA MOHAVE COUNTY In the Matter of Case Number: CONSENT OF PARENT TO NAME CHANGE OF A MINOR CHILD AND WAIVER OF NOTICE a Minor REQUIRED INFORMATION FROM PARENT, UNDER OATH OR AFFIRMATION: 1. INFORMATION ABOUT ME: Name: _______________________________________________________________________________ Address: _____________________________________________________________________________ Telephone: _________________________________ Date of Birth: _______________________ Month Place of Birth:_______________________ City I am the natural MOTHER or I am the adoptive 2. MOTHER or ___________________ Year ___________________ Nation FATHER of the minor child named above. FATHER of the minor child named above. I have read the Application for Name Change and consent to changing the child’s LEGAL name to: First: ____________________ 3. ______________________ Date ______________________ State Middle: ____________________ Last:______________________ I waive notice of all further proceedings in this matter. OATH OR AFFIRMATION STATE OF ARIZONA ) COUNTY OF MOHAVE ) ss. 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 10/23/2006 American LegalNet, Inc. www.FormsWorkflow.com