1 Code: 1067 2 Name: _______________________________ Address: _____________________________ ______________________________ Telephone Number: ____________________ Appearing in Proper Person 3 4 5 6 IN THE FAMILY DIVISION 7 OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA 8 IN AND FOR THE COUNTY OF WASHOE 9 10 In the Matter of the Application of 11 ________________________________________ (Parent’s Name Making Application) 12 Case No. ________________________ 13 natural ________________________ of the minor (Mother or Father) 14 child ____________________________________ (Child’s Name) Dept. No. ________________________ 15 16 for the change of name of the minor child. _____________________________________________/ 17 AFFIDAVIT OF SERVICE 18 STATE OF NEVADA 19 COUNTY OF WASHOE 20 __________________________________________________, being first duly sworn under (Name of Person Making Service) penalties of perjury, states as follows: 21 ) ) ss. ) 22 1. That I am: (check the appropriate blank) 23 __________ a party in this action and am appearing in proper person. 24 __________ a person not involved in this action and have no interest in this action and am over the age of 18 years. 25 26 2. That on the _______ day of __________________________, 20_______, I served a true 27 and correct copy of the documents entitled PETITION FOR CHANGE OF MINOR’S NAME and 28 NOTICE in the following way: (check the appropriate blank and fill in the appropriate information) Revised 2005 1 American LegalNet, Inc. www.FormsWorkflow.com 1 IF THE DOCUMENTS WERE SERVED BY MAIL ON THE OTHER PARENT FILL IN THE FOLLOWING: 2 3 __________ a party in this action and am appearing in proper person. 4 __________ by placing a copy enclosed in a sealed envelope upon which first class postage was fully prepaid __________ by placing a copy enclosed in a sealed envelope and mailing it certified, return receipt requested 5 6 7 8 The envelope was addressed to: 9 Name _____________________________________________________________________ 10 Address ___________________________________________________________________ 11 City, State, Zip _____________________________________________________________ 12 and that there is regular communication by mail between the place of mailing and the place 13 addressed. 14 IF THE DOCUMENTS WERE PERSONALLY SERVED ON THE OTHER PARENT FILL IN THE FOLLOWING: 15 16 __________ 17 Name _____________________________________________________________________ 18 at Address _________________________________________________________________ 19 City, State, Zip______________________________________________________________ 20 DATED this _______ day of __________________________, 20______. by personally serving: 21 ____________________________________________ (Signature) 22 23 ____________________________________________ (Print Your Name) 24 25 SUBSCRIBED and SWORN to before me 26 this _____ day of _________________________, 20_____. 27 28 ________________________________________ NOTARY PUBLIC Revised 2005 2 American LegalNet, Inc. www.FormsWorkflow.com 1 SECOND JUDICIAL DISTRICT COURT COUNTY OF WASHOE, STATE OF NEVADA 2 3 AFFIRMATION Pursuant to NRS 239B.030 4 The undersigned does hereby affirm that the preceding document, 5 6 7 (Title of Document) 8 9 filed in case number: 10 Document does not contain the social security number of any person 11 -OR- 12 Document contains the social security number of a person as required by: 13 A specific state or federal law, to wit: 14 ______________________________________________________ (State specific state or federal law) 15 16 -or- 17 For the administration of a public program 18 -or- 19 For an application for a federal or state grant 20 -or- 21 Confidential Family Court Information Sheet (NRS 125.130, NRS 125.230 and NRS 125B.055) 22 23 24 Date: (Signature) 25 26 (Print Name) 27 28 (Attorney for) Affirmation Revised December 15, 2006 American LegalNet, Inc. www.FormsWorkflow.com