PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge In the Matter of the CHANGE OF NAME OF:_______________________________________________ To________________________________________________________________________________ Case No. ______________________________ (Name Requested) (Present Name) APPLICATION FOR CHANGE OF NAME OF ADULT The Applicant states that the Applic ant is an adul t and has been a bona fide resident of Wood County, Ohio, for at least one year immediately prior to the filing of this Applicati on. 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 swears that he/she: has has not been convicted of, plead guilty to, or been does does not have a duty to adjudicated a delinquent child for committing identity fraud; and (RC 2717.01) comply with ORC 2950.04 or 2950.041 due to being convicted of, pleading guilty to, or being adjudicated a delinquent child for having committed a sexually oriented offense or child-victim oriented offense. The Applicant wishes to have his or her birth certificate changed to reflect the new name: Attorney for Applicant Typed or Printed Name Address: Applicant Typed or Printed Name Address: Yes No Phone Number (include area code) Attorney Registration Number Phone Number (include area code) Sworn to before me and subscribed in my presence this ________ day of ___________________________, _____________ _____________________________________________________ Notary Public Signature ____________________________________________________ Printed Name and Commission Expiration Date 21.0 Application for Change of Name of Adult May 2014 American LegalNet, Inc. www.FormsWorkFlow.com