IN THE PROBATE COURT OF MAHONING COUNTY, OHIO JUDGE MARK BELINKY IN THE MATTER OF A CHANGE OF NAME FOR _____________________________________________________, A MINOR (Present Name) TO: ________________________________________________________ (Name Requested) CASE NO. ____________________ APPLICATION FOR CHANGE OF NAME OF MINOR [R. C. §2717.01] The applicant is the parent or legal guardian of the Minor and that the Minor has been a bona fide resident of MAHONING County, Ohio, for at least one year immediately prior to the filing of this application. A certified copy of the Minor’s birth certificate and other proof of the applicant’s status is attached. The applicant states that the name and address of the mother of the minor is: _________________________________________________________________ Name _________________________________________________________________ Address _________________________________________________________________ City State Zip 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. An affidavit and proof in support of this statement is attached. There is no person alleged to be the father of said minor. An affidavit and proof in support of this statement is attached. The applicant requests a change of name of the minor from ___________________________________________________ (Present Name) to ______________________________________________ for the following reason:________________________________ (Name Requested) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Revised 02-29-08 American LegalNet, Inc. www.FormsWorkflow.com CASE NO: __________________ The applicant states that the applicant will cause notice of the hearing upon this application to be published once in a newspaper of general circulation in this County at least thirty (30) days before such hearing. In addition, notice of such hearing will be given by the applicant to any non-consenting parent or alleged father, whose address is known, by certified mail, return receipt requested. As to a parent whose identity or address is allegedly unknown, the applicant states that he/she will direct that such additional notice of hearing be published once each week for three consecutive weeks in a newspaper of general circulation in this County, the final publication of which shall appear at least 30 days before the hearing on this application, pursuant to Civ. R. 73(E)(6). The applicant shall file each such proof of service of notice with the Court. ______________________________________________ Attorney for Applicant ____________________________________________ Applicant’s Signature ______________________________________________ Typed or Printed Name ____________________________________________ Typed or Printed Name ______________________________________________ Full Address (No P. O. Boxes) ____________________________________________ Full Address (No P. O. Boxes) ______________________________________________ City State Zip ____________________________________________ City State Zip ______________________________________________ Telephone (Include area code) ____________________________________________ Telephone (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 ___________ , 20____, at _____O’clock __. M. The applicant is Ordered to cause notice of the application to be given once by publication in a newspaper of general circulation in this County, at least 30 days prior to the hearing date. The applicant shall also serve notice of the hearing by certified mail, return receipt requested, upon a nonconsenting parent(s), whose address is known. The applicant shall, when alleging that the identity or location of a natural parent(s) is unknown, file an affidavit for notice by publication. ____________________________________________ Hon. Mark Belinky, Judge By:_________________________________________ Deputy Clerk American LegalNet, Inc. www.FormsWorkflow.com Revised 02-29-08 American LegalNet, Inc. www.FormsWorkflow.com