COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. PROBATE COURT OF LUCAS COUNTY, OHIO : Calendar No. JACK R. PUFFENBERGER, JUDGE IN RE: CHANGE OF NAME OF : Plaintiff(s) -against- TO JUDICIAL SUBPOENA : (Present Name) : (Name Requested) : CASE NO. __________________________________ Defendant(s) : ...................................................... AFFIDAVIT (FATHER UNKNOWN) Now comes___________________________________________, as Applicant (being first duly THE PEOPLE OF THE STATE OF NEW YORK sworn* according to law) and as_____________________________________ (Relationship) of minor TO child____________________________________________________________ and requests a change of name of the above minor child to ______________________________________________________. GREETINGS: I, ___________________________________________, as Applicant, depose and state that the WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before father of said , the Honorable child: at the Court located at County of ‫ ٱ‬isthe unknown. of in room , on day , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the ‫ ٱ‬has never been determined in a legal proceeding. ‫ ٱ‬is not the subject of any action now pending to determine same. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena inaccurate for a maximum penalty of $50 and all damages sustained as a *Further, I am aware that was issued information reported in this affidavit may result in an result of your failure to comply. invalidation of the application for change of name, and that giving false information on a notarized statement is a criminal offense by Ohio Revised Code Section 2921.13A. Witness, Honorable Date:_________________________ Court in County, day of , one of the Justices of the Please Print: , 20 Your name_______________________________________ Address (Attorney must sign above and type name below) City/State/Zip Attorney(s) for Phone___________________________________________ Signature I,_____________________, Attorney-at-law, hereby certify, that the within instrument was prepared and/or examined by me, and that the same, in my opinion, is correct and proper. «ODI32.BGVK− Sworn to before me and subscribed in my presence this _____ day of ________________ 20_____. Office and P.O. Address Telephone No.: ______________________________________ Facsimile No.: NOTARY E-Mail Address: NOTARIIAL SEAL NOTAR AL SEAL Mobile Tel. No.: FORM 21-AFU – AFFIDAVIT FATHER UNKNOWN American LegalNet, Inc. www.USCourtForms.com