PROBATE COURT OF LUCAS COUNTY, OHIO JACK R. PUFFENBERGER, JUDGE 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 a 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. The applicant states that the applicant 1)_____ initials has has not been convicted of, pleaded guilty to, or been adjudicated a delinquent child for identity fraud. 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 or a child-victim oriented offense. Applicant's Signature Typed or Printed Name Address State Zip City State Zip 2)_____ initials Attorney for Applicant Typed or Printed Name Address City Telephone Number (include area code) Attorney Registration No. Telephone Number (include area code) PAGE 1 OF 2 FORM NCH 21.0 ­ APPLICATION FOR CHANGE OF NAME OF ADULT Amended: January 1, 2013 American LegalNet, Inc. www.FormsWorkFlow.com CASE 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 required by law. Judge Jack R. Puffenberger By Deputy Clerk PAGE 2 OF 2 FORM NCH 21.0 ­ APPLICATION FOR CHANGE OF NAME OF ADULT Amended: January 1, 2013 American LegalNet, Inc. www.FormsWorkFlow.com