State of Minnesota County Judicial District: Court File Number: Case Type: District Court Name Change Interpreter Requested Language In the Matter of the Application of (current name): First Middle Last First Middle Last First Middle Last For a change of name to (new name): Application for Name Change And Other Relief (Minn. Stat. § 259.10) Last First Middle First Middle Last First Middle Last State of Minnesota County of ) ) SS ) The undersigned applicant states that: 1. This application is made in good faith, without intent to defraud or mislead. 2. All persons who are asking to have their names changed on this application have lived in the State of Minnesota for at least six months immediately prior to the date of this application, and now live at: Street City/Town State Zip County 3. Name of applicant and date of birth: 4. Name of applicant's spouse and date of birth: This application does does not include spouse. NAM102 State ENG Rev 07/15 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 3 5. Name(s) of minor child(ren) and date(s) of birth: This application does not include minor child(ren) listed above. This application includes the following minor child(ren) listed above: 6. The name and address of the non-applicant parent of the minor child(ren included in this Application is: The non-applicant parent is not known and his/her name is not shown on the birth certificate. 7. Applicant requests: To have his/her name changed from to To have his/her name changed on the birth record created or maintained by the Minnesota Department of Health to (must reflect your current name or the proposed name if you checked the box above) To have his/her sex changed on the birth record created or maintained by the Minnesota Department of Health from to . To have the Minnesota Department of Health issue and register a replacement birth record. Applicant further requests the prior birth record be kept confidential and the replacement birth record not to include any reference to Applicant's former name former sex. To have the name of his/her spouse changed to To have the names of his/her minor child(ren) changed to NAM102 State ENG Rev 07/15 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 8. No party to this application has a criminal history OR The criminal history of the following parties included in this application is: The following parties included in this application have been convicted of a felony: List name, date of offense, and state. 9. Legal description of lands in the State of Minnesota upon which the following have a claim, interest, or lien: (Provide the legal description and attach additional pages if necessary) Applicant Spouse Child(ren) 10. Applicant is currently involved in a victim or witness protection program. 11. Applicant is an inmate in a correctional facility, and has attached the Inmate Affidavit for Name Change. 12. Other: I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116. Date: Applicant's Signature Address City ( ) Telephone Number E-mail address Co-applicant's Signature (Spouse) Minor's Signature (14 or older) State Zip NAM102 State ENG Rev 07/15 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3