352%$7( &2857 2) 7580%8// &2817< 2+,O JAMES A. FREDERICKA, JUDGE ,1 5( &+$1*( 2) 1$0( 2)BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 72 BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB &$6( 12 BBBBBBBBBBBBBBBBBBBBBBB 1DPH 5HTXHVWHG 3UHVHQW 1DPH $33/,&$7,21 )25 &+$1*( 2) 1$0( 2) $'8/7 >5& @ The applicant states that the applicant is an adult and has been a bona fide resident of ______________ County, Ohio, for at 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 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. _____________________________________ Applicant's Signature _____________________________________ Typed or Printed Name _____________________________________ Address ______________________________________ City State Zip _____________________________________ Telephone Number (include area code) ______________________________________ Attorney for Applicant ______________________________________ Typed or Printed Name ______________________________________ Address ______________________________________ City State Zip ______________________________________ Telephone Number (include area code) Attorney Registration No. __________________ )250 $33/,&$7,21 )25 &+$1*( 2) 1$0( 2) $'8/7 $PHQGHG -DQXDU\ 'LVFDUG DOO SUHYLRXV YHUVLRQV RI WKLV IRUP American LegalNet, Inc. www.FormsWorkFlow.com [Reverse of Form 21.0] &$6( 12BBBBBBBBBBBBBB -8'*0(17 (175< 6(77,1* +($5,1* $1' 25'(5,1* 127,&( 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 )250 $33/,&$7,21 )25 &+$1*( 2) 1$0( 2) $'8/7 3$*(  $PHQGHG -DQXDU\ 'LVFDUG DOO SUHYLRXV YHUVLRQV RI WKLV IRUP American LegalNet, Inc. www.FormsWorkFlow.com