State of Minnesota County Judicial District: Court File Number: Case Type: District Court Name Change In the Matter of (current name on birth record): First Middle Last Motion to Replace Birth Record (Minn. Stat. § 144.218, subdivision 4) Date of Birth: _______________________________ PLEASE TAKE NOTICE that the undersigned will bring a motion before the Honorable , on (Name of Judge) (Date: Month, Day, Year) at (Time) .m. at the County Courthouse / Government Center located at in the city of (Street address where hearing to be held) , Minnesota, and will ask the court to issue an order directing the Minnesota Department of Health to change and issue a replacement birth record for the Applicant as requested in the following motion. Motion 1. This motion is made in good faith, without intent to defraud or mislead. 2. The Applicant previously requested and the court granted his/her name change from to 3. Applicant has has not amended his/her birth record to reflect Applicant's name change. 4. Applicant requests: To have the birth record created or maintained by the Minnesota Department of Health replaced to reflect the name change from to To have the sex changed from to created or maintained by the Minnesota Department of Health. . on the birth record 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. NAM113 State ENG Rev 07/15 www.mncourts.gov/forms Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com  To change the following other item: 5. Applicant states that the item(s) identified in paragraph 4 above are incomplete, inaccurate, or false for the following reason(s) (supporting documentation required): 6. Applicant requests the court to issue an order directing the Minnesota Department of Health to issue and register a replacement birth record. Date: Applicant's Signature Minor's signature (14 years of age or older) Address City, State, Zip E-mail address Telephone number NAM113 State ENG Rev 07/15 www.mncourts.gov/forms Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com