TED KLAMMER, JUDGE PROBATE COURT OF LAKE COUNTY, OHIO 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 ____________________ 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. Applicant’s birth name is______________________________________________________________________________, The applicant was born on ______________________ in_______________________, (City) _____________, ________________. (County) (State) _____________________________________ _________________________________________ Attorney for Applicant Applicant’s Signature _____________________________________ _________________________________________ Typed or Printed Name Typed or Printed Name _____________________________________ _________________________________________ Address Address _____________________________________ _________________________________________ City City State Zip State Zip _____________________________________ _________________________________________ Telephone Number (include area code) Telephone Number (include area code) Attorney Registration No. ________________ FORM 21.0 – APPLICATION FOR CHANGE OF NAME OF ADULT American LegalNet, Inc. www.FormsWorkFlow.com [Side 2 of Form 21.0] JUDGEMENT 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 American LegalNet, Inc. www.FormsWorkFlow.com