For Clerk’s Use Only SUPERIOR COURT OF ARIZONA IN MOHAVE COUNTY In the Matter of: ______________________________ A Minor Case Number: ______________________ ORDER CHANGING NAME OF MINOR THE COURT FINDS: 1. 2. 3. 4. This case has come before this Court to change the legal name of the minor named above. This Court has jurisdiction to change the legal name of the minor. Good cause exists to grant the application for change of legal name. It is in the best interest of the minor to change the legal name as set forth below. THE COURT ORDERS: 1. That the legal name of the minor born this date: ____________ ___________ ____________ (Month) (Day) (Year) Place of Birth: _____________________ ____________________ ______________________ (City) (State) (Nation) Whose mother is: __________________ ____________________ ______________________ (First) (Middle) (Last) IS CHANGED FROM: Name on Birth Certificate _________________________ _________________________ _________________________ (First) (Middle) (Last) TO: New Name _________________________ _________________________ _________________________ (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. This Order does not establish paternity or add the name of a father to a birth certificate. 10/16/2006 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Case No.________________ 4. This Order does not release the minor child or either parent named above from any obligations incurred or harm any rights of property or action in any original name. 5. Other orders: DONE IN OPEN COURT: Date 10/16/2006 Judicial Officer Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com