PROBATE COURT OF HAMILTON COUNTY, OHIO RALPH WINKLER, 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 has been a bona fide resident of______________ County, Ohio, for at least one year 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) _______ has has not been convicted of, pleaded guilty to, or been adjudicated a delinquent initials child for identity fraud. 2) _______ has a has no duty to comply with R.C. 2950.04 or R.C. 2950.041 because the initials 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. ___________________________________ Attorney for Applicant ___________________________________ Typed or Printed Name ___________________________________ Address ___________________________________ City State Zip ___________________________________ Applicant's Signature ___________________________________ Typed or Printed Name ___________________________________ Address ___________________________________ City State Zip (____)______________________________ Telephone Number (include area code) Attorney Registration No._______________ (____)______________________________ Telephone Number (include area code) H.C. FORM 21.0 - APPLICATION FOR CHANGE OF NAME OF ADULT 01/01/13 American LegalNet, Inc. www.FormsWorkFlow.com