PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. MCCOLLUM, 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 Ohio, for at least one year immediately prior to the filing of this application. County, 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 fraud. has not been convicted of, pleaded guilty to, or been adjudicated a delinquent child for identity 2) initials 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. FORM 21.0 - APPLICATION FOR CHANGE OF NAME OF ADULT Amended: January 1, 2013 American LegalNet, Inc. www.FormsWorkFlow.com (Reverse of Form 21.0) Attorney for Applicant Typed or Printed Name Address City State Zip Applicant's Signature Typed or Printed Name Address City State Zip Telephone Number (include area code) Attorney Registration No. Telephone Number (include area code) JUDGMENT 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. Probate Judge By: Deputy Clerk FORM 21.0 - APPLICATION FOR CHANGE OF NAME OF ADULT PAGE 2 Amended: January 1, 2013 American LegalNet, Inc. www.FormsWorkFlow.com