Name of Person Filing: Street Address: City, State, Zip Code: Telephone Number: Email Address: ATLAS Number (if applicable) Representing Self (No Attorney) If Attorney, Bar Number: or Represented by Attorney SUPERIOR COURT OF ARIZONA PINAL COUNTY In the Matter of: CASE NUMBER: CV2 APPLICATION FOR CHANGE OF NAME FOR AN ADULT Name of Applicant HONORABLE: STATEMENTS TO THE COURT, UNDER OATH 1. INFORMATION ABOUT ME, THE APPLICANT Name on Birth Certificate or Current Legal Name: Address: Date of Birth: Place of Birth: County of Residence: I ask that my name be changed to: (First) (Middle) (Last) 2. I ask that the birth records be ordered changed to reflect the new name listed above. 3. REASON FOR THIS REQUEST FOR CHANGE OF NAME: 4. STATEMENTS TO THE COURT REQUIRED BY ARIZONA LAW (A.R.S. �12-601(C)) Check the boxes that indicate a true statement. a. I submitted this application solely for the benefit and in the best interest of the person for whom the name change is requested. CV_ANCA_COSCPinal_04.09.12 Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 3 b. I understand and acknowledge that this change of name, if granted, will not release me from any obligation incurred or harm any rights of property or action in any previous name. I am not knowingly requesting this change of name to that of another individual for the purpose of committing or furthering any offense of theft, forgery, fraud, perjury, organized crime or terrorism or any other offense involving false statements. Have you or any adult listed above ever been convicted of a felony? If "yes", list all felony convictions on next page. Yes No c. d. If "Yes" to statement "d" all felony convictions are listed below. Felony Case No. County and State Sentence Date of Conviction 1 2 3 4 Is there anything regarding your felony conviction(s) that you would like to bring to the Court's attention? (Optional) e. Are there any criminal charges (felony or misdemeanor) pending against you at this time? Yes No If "Yes" to "e" all pending charges are listed below: Pending Charges Name of Court or City & State Case No. 1 2 3 4 Is there anything regarding your pending criminal charges that you would like to bring to the Court's attention? (Optional) Page 2 of 3 CV_ANCA_COSCPinal_04.09.12 Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com OATH AND VERIFICATION OF APPLICANT: STATE OF ARIZONA COUNTY OF PINAL ) ) ss. ) I, the Applicant, being duly sworn and under oath, state that I have read this Application. All the statements in the Application are true, correct, and complete to the best of my knowledge and belief. (Applicant's Signature) SUBSCRIBED AND SWORN TO before me this day of 20 By My Commission Expires: (Deputy Clerk/Notary Public) Page 3 of 3 CV_ANCA_COSCPinal_04.09.12 Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com