PROBATE COURT OF ____________________ COUNTY, OHIO _______________________, JUDGE IN RE: CHANGE OF NAME OF (Present Name) (Name Requested) _ _______________ TO___________________________________________________________________ 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 Zip and the name and address of Parent 2 or alleged father of the minor is: _______________________________________________________ Name _______________________________________________________ Address _______________________________________________________ City Zip Applicant states that the address of Parent 1 with reasonable diligence be ascertained. Parent 2 or alleged father is unknown and cannot There is no person alleged to be the father of the minor. The applicant states that the person for whom a change of name is being requested 1)_________ Initials 2) ________ Initials has has not been convicted of, pleaded guilty to, or been adjudicated a delinquent child for identity fraud. 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 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Reverse of Form 21.2] 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 ______________________________________ Applicant's Signature _________________________________________ Typed or Printed Name _________________________________________ Address _________________________________________ City State Zip _________________________________________ Telephone Number (include area code) Attorney Registration No. _____________________ ______________________________________ Typed or Printed Name ______________________________________ Address ______________________________________ City State Zip ______________________________________ Telephone Number (include area code) FORM 21.2 ­ APPLICATION FOR CHANGE OF NAME OF MINOR Amended: March 15, 2016 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com