State of Minnesota County Judicial District: Court File Number: Case Type: District Court In the Matter of: First Middle Last Order Granting Replacement Birth Record (Minn. Stat. § 144.218, subdivision 4) Date of Birth:_________________________ The above entitled matter came on for hearing before the undersigned Judge on upon the Applicant's Motion to Replace Birth Record. appeared on behalf of the Applicant. Applicant, hearing. was was not present at the Based upon all files, records, and proceedings herein, along with the submissions of the Applicant, the Court makes the following: 1. The motion is made in good faith without intent to defraud or mislead. 2. Applicant has previously been granted a name change. 3. The current birth record is incomplete, inaccurate, or false. 4. Other: The Motion is granted and IT IS ORDERED that: 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 to . NAM114 State ENG 08/14 www.mncourts.gov/forms Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com  The Minnesota Department of Health shall change 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 Other . Dated: Judge of District Court NAM114 State ENG 08/14 www.mncourts.gov/forms Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com