Approved, SCAO PCS CODE: OCN TCS CODE: OCN STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION FILE NO. ORDER FOLLOWING HEARING ON PETITION TO CHANGE NAME COUNTY In the matter of the name change of Present first name(s), middle name(s), and last name(s) (type or print) 1. Date of Hearing: THE COURT FINDS: 2. A petition for name change has been filed. 3. Notice of hearing was given by publication. Judge: Bar no. 4. Each person for whom a name change is sought has been a resident of the county for at least one year. 5. The court has received the required criminal record report(s) from the Michigan Department of State Police. 6. Name (type or print) Name (type or print) has a criminal record. 7. The request for the name change of is is not made with fraudulent intent. 8. The petitioner, having legal custody, requests the name change of a minor. The noncustodial parent has consented to the name change. 9. The petitioner requests the name change of a minor. The custodial parent has consented to the name change. The noncustodial parent was given notice of the hearing. a. The noncustodial parent has had the ability to visit, contact, or communicate with the minor but has regularly and substantially failed or neglected to do so for the past two years, and a support order has been entered, and the noncustodial parent has failed to substantially comply with the order for a period of two years or more before the filing of the petition for name change. or a support order has not been entered and the noncustodial parent, having the ability to support or assist supporting the child, has failed or neglected to provide regular and substantial support for two years or more before the filing of the petition for name change. b. The noncustodial parent has been convicted of child abuse (MCL 750.136b), criminal sexual conduct (MCL 750.520b, 750.520c, 750.520d, or 750.520e), or assault with intent to commit criminal sexual conduct (MCL 750.520g), and the child or a sibling of the child was the victim. 10. The minor(s) 14 years of age or older signed a written consent to change name in the presence of the court. 11. The minor(s) under the age of 14 has/have stated a preference to a name change. 12. The minor(s) is/are not of sufficient age to express a preference to a name change. (SEE SECOND PAGE) Do not write below this line - For court use only American LegalNet, Inc. www.FormsWorkFlow.com PC 52 (9/16) ORDER FOLLOWING HEARING ON PETITION TO CHANGE NAME MCL 333.2872, MCL 711.1, MCR 3.613 Order Following Hearing on Petition to Change Name (9/16) File No. 13. The name(s) of the following person(s) is/are changed. FROM Petitioner Spouse Minor child Minor child Minor child Minor child TO DATE OF BIRTH month, day, year month, day, year month, day, year month, day, year month, day, year month, day, year 14. The State Registrar shall create a new live birth certificate for Name that does not disclose the name at birth and shall seal the original certificate. 15. The request to change the name of Name is denied. 16. The request is denied and the petition is dismissed. Date Judge Attorney Name (type or print) Address City, state, zip Bar no. Telephone no. Note to Petitioner: You must provide this order to the State Registrar if you want to change your birth certificate. Note to Clerk: Under MCL 711.1(3), if the court enters an order to change the name of a person who has a criminal record, the court shall forward the order to the Criminal Justice Information Center of the Michigan State Police and to one or more of the following: from parole in the immediately preceding two years. jail or released from a county jail within the immediately preceding two years. of the family division of the circuit court. American LegalNet, Inc. www.FormsWorkFlow.com