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: First Middle Last On Behalf of (current name of minor(s)): First Middle Last Application for Name Change of a Minor (Minn. Stat. § 259.10) First Middle Last For a change of name to (new name of minor(s)): First Middle Last First Middle Last STATE OF MINNESOTA COUNTY OF The undersigned applicant states that: ) ) SS ) 1. This application is made in good faith, without intent to defraud or mislead. 2. The minor child(ren) whose name(s) are sought to be 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: No. City/Town Street State Zip County 3. I am/we are the: (check one) parent(s) legal guardian next of kin (specify): minor child(ren). of the NAM202 State ENG Rev 9/15 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 4. The current name(s) of minor child(ren) and date(s) of birth: 5. The name of the non-applicant parent(s): The non-applicant parent is not known and his/her/their name(s) is/are not shown on the birth certificate. 6. The address of the non-applicant parent(s) is/are: No. City/Town State Zip Street County 7. Applicant requests to have the name(s) of the minor child(ren) changed to: 8. 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. If no criminal history, write "No criminal history." If no felony convictions, write "No felony convictions." _ _ 9. Legal description of lands in the State of Minnesota upon which the minor child(ren) has/have a claim, interest, or lien: (Provide the legal description and attach additional pages if necessary) 10. Other: I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116. Dated: Co-Applicant's Signature (Spouse) Applicant's Signature Minor Signature (14 years or older) Address Minor Signature (14 years or older) City State Zip ( ) Telephone Number E-mail address NAM202 State ENG Rev 9/15 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2