PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, JUDGE IN RE: CHANGE OF NAME OF (Present Name) TO (Name Requested) CASE NO. APPLICATION FOR CHANGE OF NAME OF MINOR [R.C. 2717.01] The applicant states that the applicant is the parent legal guardian guardian ad litem of the minor and that the minor has been a bona fide resident of County, Ohio, for at least one year prior to the filing of this application. A copy of the minor's birth certificate which was certified and shown to the Court is attached. The applicant states that the name and address of the mother of the minor is: Name Address City Zip State and the name and address of the father or alleged father of the minor is: Name Address City Zip State Applicant states that the address of the mother father or alleged father is unknown and cannot with reasonable diligence be ascertained. There is no person alleged to be the father of said minor. The applicant requests a change of name of the minor from to for the following reason: Page 1 of 2 H.C. FORM 21.2 - APPLICATION FOR CHANGE OF NAME OF MINOR 12/03/03 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. 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 days before the hearing on this application. In addition, notice will be given by the applicant to any non-consenting parent or alleged father, whose addresses are known, by certified mail, return receipt requested. Attorney for Applicant Applicant's Signature Typed or Printed Name Typed or Printed Name Address Address City State Zip ( ) Telephone Number (include area code) City State Zip ( ) Telephone Number (include area code) Attorney Registration No. Page 2 of 2 H.C. FORM 21.2 - APPLICATION FOR CHANGE OF NAME OF MINOR American LegalNet, Inc. www.FormsWorkflow.com