State of Minnesota County Judicial District: Court File Number: Case Type: District Court Name Change In the Matter of: First Middle Last Order Granting Name Change And Other Relief For a change of name to: (Minn. Stat. § 259.10, § 144.218, and § 144.2181) First Middle Last The above entitled matter came on for hearing before the undersigned Judge on _________________________ upon the Application for a Name Change and Other Relief. Upon the Date testimony and files, THE COURT FINDS the following: 1. The application is made in good faith without intent to defraud or mislead. 2. The applicant(s) has/have lived in the State of Minnesota for at least six months preceding the filing of the application, and now live at: Street City/Town State Zip in 3. Name of applicant and date of birth: County. 4. Name of spouse and date of birth: This application does does not include spouse. 5. Name(s) of minor children and date(s) of birth: This application does not include minor children listed above. This application includes the following minor children listed above: NAM107 State ENG Rev 08/14 www.mncourts.gov/forms Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 6. This applicant requests: To have his/her name changed to To have his/her name changed on birth records created or maintained by the Minnesota Department of Health to To have his/her sex changed on birth records created or maintained by the Minnesota Department of Health 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 name(s) of his/her child (ren) changed to 7. The applicant (and included spouse or child (ren)) Has not been convicted of a felony in any state. Has been convicted of a felony as follows: AND Proper notice has been given to the prosecuting authority and Minnesota Attorney General AND No objection has been filed. 8. 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) 9. Other: . The application is granted and IT IS ORDERED that: The legal name of the Applicant shall be The legal name of the spouse shall be NAM107 State ENG Rev 08/14 www.mncourts.gov/forms Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com  The legal names of the minor child (ren) shall be The Minnesota Department of Health shall change the name on the birth record from to The Minnesota Department of Health shall change the sex on the birth record from . The Minnesota Department of Health shall issue and register a replacement birth record for the Applicant. The prior birth record shall be confidential pursuant to Minn. Stat. § 13.02, subdivision 3, and shall not be disclosed except pursuant to court order. The replacement birth record shall not include any reference to the Applicant's former name former sex and shall reflect the Applicant's current legal name of shall reflect the sex designation of . . to All persons having a criminal history who have been granted a name change by this court have a duty to report that name change to the Bureau of Criminal Apprehension within ten (10) days of this order. Other Dated: Judge of District Court DUTY TO REPORT NAME CHANGE Minn. Stat. § 259.11B If you have a criminal history and have changed your name, you have a duty to report your name change to the Bureau of Criminal Apprehension located at 1430 East Maryland Avenue, St Paul, MN 55106, (651)7932400, within ten (10) days of this order. Failure to do so is a gross misdemeanor punishable by up to one (1) year in prison and/or a fine of $3000. NAM107 State ENG Rev 08/14 www.mncourts.gov/forms Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com