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 MINOR [R.C. 2717.01] The applicant states that the applicant is the minor has been a bona fide resident of prior to the filing of this application. parent legal guardian guardian ad litem of the minor and that the _ County, Ohio, for at least one year immediately A certified copy of the minor's birth certificate is attached. The applicant states that the name and address of the mother of the minor is: _ Name Address _ City State Zip and the name and address of the father or alleged father of the minor is: _ Name Address _ City Applicant states that the address of the reasonable diligence be ascertained. mother State Zip father or alleged father is unknown and cannot with There is no person alleged to be the father of the minor. The applicant states that the person for whom a change of name is being requested has has not been convicted of, pleaded guilty to, or been adjudicated a delinquent child for 1) initials identity fraud. 2) initials has a has no duty to comply with R.C. 2950.04 or R.C. 2950.041 because the applicant was convicted of, pled guilty to, or was adjudicated a delinquent child for having committed a sexually oriented offense or a child-victim oriented offense FORM 21.2 ­ APPLICATION FOR CHANGE OF NAME OF MINOR Amended: January 1, 2013 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Reverse of Form 21.2] CASE NO. _____________ The applicant requests a change of name of the minor 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. In addition, notice will be given by the applicant to any non-consenting parent or alleged father, whose addresses are known, by certified mail, return receipt requested. Attorney for Applicant Applicant's Signature Typed or Printed Name Typed or Printed Name Address _____________________________________________ City State Zip Address _____________________________________________ City State Zip Telephone Number (include area code) Attorney Registration No. Telephone Number (include area code) JOURNAL 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 well as certified mail service, return receipt requested, if necessary, as required by law. Probate Judge By: Deputy Clerk FORM 21.2 ­ APPLICATION FOR CHANGE OF NAME OF MINOR (PAGE 2) Amended: January 1, 2013 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com