PROBATE COURT OF _ _ _ _ _ _ COUNTY, OHIO INRE:CHANGEOFNAMEOF____________~~~__--------------- (present N......) CASE NO. _________________ (Name Requuted) [R.C.2717.01] TO ______________________~-=--~------------------------ APPLICATION FOR CHANGE OF NAME OF ADULT The applicant states that the applicant is an adult and has been a bona fide resident of _ _ _ _ _ _ County, Ohio, for at least one year immediately prior to the filing of this application. The applicant requests a change of name from _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ w~~~~----------------------------------for the following reason: _______________________________ The applicant states that the applicant will cause notice of the application to be pubHshed 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) _ _ inltiall 0 has fraud. 0 has not been convicted of, pleaded guilty to, or been adjudicated a delinq uent child for identity 2) _ _ initials 0 has a 0 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. Attomey for Applicant Typed or Printed Name Address City State Zip Applicanfs Signature Typed or Printed Name Address City state Zip Telephone Number (Include area code) Attomey Registration No. _ _ _ _ _ __ Telephone Number (include area code) FORM 21.0 · APPUCATION FOR CHANGE OF NAME OF ADULT Amended: January 1. 2013 Discard all previous version. of this form American LegalNet, Inc. www.FormsWorkFlow.com [Reverse of Form 21.0) CASE NO,_ _ _ __ 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 · APPUCATION FOR CHANGE OF NAME OF ADULT (pAGE 2) ~:January1,2013 Dlac:ard aI' pnMou. versions ofthis form American LegalNet, Inc. www.FormsWorkFlow.com