PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE IN THE MATTER OF THE NAME CHANGE OF _______________________________ (Present Legal Name) (CHECK THE APPROPRIATE BOX) I, the applicant in the above-captioned case first being duly sworn say that service was made by certified mail on: ____________________________________ (PERSON SERVED) on the _________ day of ____________________________, 20 ______. The RETURN RECEIPT CARD is attached to the back of this Affidavit. : : : AFFIDAVIT REGARDING SERVICE CASE NO.: ____________________ OR I, the applicant in the above-captioned case first being duly sworn say that I attempted service on: ____________________________________ (PERSON ATTEMPTED TO BE SERVED) on the _________ day of ____________________________. 20 ______. I further state that the notice sent by certified mail was returned: (CHECK ONE OF THE FOLLOWING): ___UNCLAIMED ___REFUSED ___OTHER on the _________ day of ___________________________, 20 _______. The original ENVELOPE and RETURN RECEIPT CARD are attached to the back of the Affidavit. I then mailed the notice of this hearing by ordinary mail to: _____________________________________ (PERSON TO BE SERVED) on the _________ day of ___________________________, 20_______. I further state that the envelope has not been returned by the postal authorities as being undelivered. The post office PROOF OF MAILING is attached to the back of this Affidavit. __________________________________ AFFIANT Sworn to before me and subscribed in my presence by _________________________ this _______ day of ________________, 20______. __________________________________ NOTARY M.C. FORM 21.6 ­ AFFIDAVIT REGARDING SERVICE 05/04/2012 American LegalNet, Inc. www.FormsWorkFlow.com