For Clerk's Use Only SUPERIOR COURT OF ARIZONA IN MOHAVE COUNTY In the Matter of: ______________________________ Name of Applicant Case Number: ______________________ ORDER CHANGING NAME OF AN ADULT THE COURT FINDS: 1. 2. 3. This case has come before this Court to change the legal name of the Applicant. This Court has jurisdiction to change the legal name of the Applicant. Good cause exists to grant the application for change of legal name. THE COURT ORDERS: 1. The name on the Birth Certificate or the Current Legal Name: _________________________ _________________________ _________________________ (First) (Middle) (Last) Date of Birth: _____________________ ____________________ ______________________ (Month) (Day) (Year) Place of Birth: _____________________ ____________________ ______________________ (City) (State) (Nation) IS CHANGED TO: _________________________ _________________________ _________________________ (First) (Middle) (Last) 2. For a person born in the State of Arizona, the Office of Vital Records is ordered to amend the birth record to reflect the new name as ordered above. For a person born in a state other than Arizona, to the extent that the agency that maintains birth records in that state is authorized to honor an order of this Court, that agency is requested or ordered to amend its birth records to reflect the new name as ordered above. 3. 4. This Order does not release the Applicant from any obligations incurred or harm any rights of property or action in any original name. Other orders; __________________________________________________________________ DONE IN OPEN COURT: Date Judicial Officer 10/16/2006 American LegalNet, Inc. www.FormsWorkflow.com