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 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 immediately prior to the filing of this application. A certified copy of the minor’s birth certificate 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 requests a change of name of the minor from __________________________________________ to _______________________________________________________________________________________ for the following reason: _____________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ FORM 21.2 – APPLICATION FOR CHANGE OF NAME OF MINOR American LegalNet, Inc. www.FormsWorkFlow.com [Side 2 of Form 21.2] 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 address are known, by certified mail, return receipt requested. ______________________________________ Attorney for Applicant _________________________________________ Applicant’s Signature ______________________________________ Typed or Printed Name _________________________________________ Typed or Printed Name ______________________________________ Address _________________________________________ Address ______________________________________ City State Zip _________________________________________ City State Zip ______________________________________ Telephone Number (include area code) _________________________________________ Telephone Number (include area code) Attorney Registration No. _________________ JOURNAL 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 well as certified mail service, return receipt requested, if necessary, as required by law. _________________________________________ Probate Judge By: _________________________________________ Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com