IN THE WARREN COUNTY, OHIO COMMON PLEAS COURT PROBATE DIVISION 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 immediately prior to the filing of this application. A certified copy of the minor's birth certificate is attached. The applicant states that the name and address of Parent 1 of the minor is: ___________________________________________________________________ Name ___________________________________________________________________ Address ___________________________________________________________________ City State Zip and the name and address of Parent 2 or alleged father of the minor is: ___________________________________________________________________ Name ___________________________________________________________________ Address ___________________________________________________________________ City State Zip Applicant states that the address of Parent 1 Parent 2 or cannot with reasonable diligence be ascertained. There is no person alleged to be the father of the minor. alleged father is unknown and The applicant states that the person for whom a change of name is being requested 1) _______ Initials has has not been convicted of, pleaded guilty to, or been adjudicated a delinquent child for identity fraud 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 21.2 - APPLICATION FOR CHANGE OF NAME OF MINOR Amended: March 15, 2016 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. _________________ The applicant requests a change of name of the minor 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. In addition, notice will be given by the applicant to any non-consenting parent or alleged parent, whose addresses are known, by certified mail, return receipt requested. ____________________________________ Attorney for Applicant ____________________________________ Typed or Printed Name ____________________________________ Address ____________________________________ City State Zip ____________________________________ Telephone Number (include area code) _____________________________________ Applicant's Signature ____________________________________ Typed or Printed Name ____________________________________ Address ______________________________________ City State Zip _____________________________________ Telephone Number (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 ___________________, _______, 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 well as certified mail service, return receipt requested, if necessary, as required by law. ___________________________________ Probate Judge By: ___________________________________ Deputy Clerk FORM 21.2 - APPLICATION FOR CHANGE OF NAME OF MINOR PAGE 2 Amended: March 15, 2016 American LegalNet, Inc. www.FormsWorkFlow.com