PROBATE COURT OF ________________ COUNTY, OHIO IN RE: CHANGE OF NAME OF__________________________________________________ (Present Name) TO ________________________________________________________________________ (Name Requested) CASE NO. _______________________ APPLICATION FOR CHANGE OF NAME OF ADULT [R.C. 2717.01] 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 has 1) _____ initials fraud. 2) _____ initials has not been convicted of, pleaded guilty to, or been adjudicated a delinquent child for identity 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. __________________ FORM 21.0 - APPLICATION FOR CHANGE OF NAME OF ADULT Amended: January 1, 2013 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com (Reverse of Form 21.0) JUDGMENT 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 required by law. ______________________________________ Probate Judge By: _____________________________________ Deputy Clerk FORM 21.0 - APPLICATION FOR CHANGE OF NAME OF ADULT (PAGE 2) Amended: January 1, 2013 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com