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 MINOR [R.C. 2717.01] The applicant states that the applicant is the parent legal guardian guardian ad litem of the minor and that the minor has been a bona fide resident of ______________ County, Ohio, for at least one year prior to the filing of this application. A copy of the minor's birth certificate which was certified and shown to the Court 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 State Zip Applicant states that the address of the mother father or alleged father is unknown and cannot with reasonable diligence be ascertained. There is no person alleged to be the father of said minor. The applicant states that the person for whom a change of name is being requested 1) ______ has has not been convicted of, pleaded guilty to, or been adjudicated a initials delinquent child for identity fraud. 2) ______ has a has no duty to comply with R.C. 2950.04 or R.C. 2950.041 because initials the applicant was convicted of, plead guilty to, or was adjudicated a delinquent child for having committed a sexually oriented offense or a child-victim oriented offense. American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 H.C. FORM 21.2 - APPLICATION FOR CHANGE OF NAME OF MINOR 01/01/13 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 ___________________________________ 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) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 H.C. FORM 21.2 - APPLICATION FOR CHANGE OF NAME OF MINOR 01/01/13