PROBATE COURT OF CUYAHOGA COUNTY, OHIO ANTHONY J. RUSSO, PRESIDING JUDGE LAURA J. GALLAGHER, JUDGE IN RE: CHANGE OF NAME OF (Present Name) TO (Name Requested) CASE NO. APPLICATION FOR CHANGE OF NAME OF ADULT [R.C. 2717.01] The applicant states that the applicant is an adult and has been a bona fide resident of Cuyahoga County, Ohio, for at least one year immediately prior to the filing of this application. The applicant requests a change of name from to for the following reason: ___________________________________________________________________________________________________ . The applicant states that the applicant will cause notice of the application to be published once in a newspaper of general circulation in this county at least thirty (30) days before the hearing on this application. The applicant states that the applicant 1) Initials has has not been convicted of, pleaded guilty to, or been adjudicated a delinquent child for identity fraud. has no duty to comply with R.C. 2950.04 or R. C. 2950.041 because the applicant was has convicted of, pled guilty to, or was adjudicated a delinquent child for having committed a sexually oriented offense or a child-victim oriented offense. 2) Initials Attorney for Applicant Applicant's Signature Typed or Printed Name Typed or Printed Name Address ___________________________________________ City State Zip _ Telephone Number (include area code) Attorney Registration No. Address __________________________________________ City State Zip Telephone Number (include area code) FORM 21.0 ­ APPLICATION FOR CHANGE OF NAME OF ADULT Amended: January 1, 2013 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com (Reverse of Form 21.0) JUDGMENT ENTRY SETTING HEARING AND ORDERING NOTICE The Court orders this application set for hearing on the day of _ _, at o'clock .m. The applicant is ordered to cause notice of the application to be given by one publication in a newspaper of general circulation in this county at least thirty (30) days prior to the hearing date as required by law. Probate Judge By: Deputy Clerk FORM 21.0 ­ APPLICATION FOR CHANGE OF NAME OF ADULT (PAGE 2) Amended: January 1, 2013 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com