PRINT CLEAR PROBATE COURT OF LAKE COUNTY, OHIO MARK J. BARTOLOTTA, JUDGE IN RE: CHANGE OF NAME OF ____________________________________________________________ TO ________________________________________________________________________________ CASE NO. ____________________ 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 ____________________________________________________________ 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 the county at least thirty (30) days before the hearing on the application. The applicant states that the applicant 1) _____ Initial has has not been convicted of, pleaded guilty to, or been adjudicated a delinquent child for identity fraud 2) _____ Initial 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 of a child-victim oriented offense. Attorney for applicant _______________________________________ _______________________________________ _______________________________________ Address City Applicant's Signature ____________________________________________ Typed or printed Name Typed or printed Name ____________________________________________ ____________________________________________ Address _______________________________________ State Zip ____________________________________________ City State Zip _______________________________________ Telephone Number ( include area code ) Attorney Registration No.________________________________ ____________________________________________ Telephone Number ( include area code ) FORM 21.0 ­ APPLICATION FOR CHANGE OF NAME OF ADULT Amended: January 1, 2013 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 ­ APPLICATION OF CHANGE OF NAME OF ADULT AMENDED: January 1, 2013 American LegalNet, Inc. www.FormsWorkFlow.com PROBATE COURT OF LAKE COUNTY, OHIO MARK J. BARTOLOTTA, JUDGE IN RE: CHANGE OF NAME OF TO (Present Name) (Name Requested) CASE NO. ADDENDUM TO APPLICATION FOR CHANGE OF NAME OF ADULT The applicant, being duly sworn, states the following: 1. Applicant is not a "habitual sex offender" as defined under Ohio Revised Code section 2950.01. A "habitual sex offender" includes any person who is convicted two or more times, in separate criminal actions, for commission of any of the sex offenses set forth in division (B) of this section. Convictions which results from or are connected with the same act, or result from offenses committed at the same time, shall be counted for the purpose of this section as one conviction. Any conviction set aside pursuant to law, is not a conviction for other purposes of this section. 2. Application is not seeking to avoid any legal responsibilities of the application of any laws of the United States or the State of Ohio. 3. Applicant does not have any outstanding warrants from any governmental body. 4. Applicant's birth name is 5. Applicant was born on (State) , in (County) . (City) (Applicant) Sworn to before me, and signed in my presence, the day of , 20 Notary Public/Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com