1 2 3 4 IN THE CIRC UIT COURT OF THE STATE OF OREGON 5 FOR THE THIRD JUDICIAL DISTRICT 6 7 In the Matter of the Change of Name of: ) ) 8 __________________________________________ ) Case No: _____________ ) 9 __________________________________________ ) AFFIDAV IT FOR (Present Name(s) of Minor Child/ren) ) MOTION TO WAIVE10 ) NOTICE TO THE OTHER __________________________________________ ) PARENT11 ) __________________________________________ ) 12 (Proposed Name(s) of Minor Child/ren) ) ) 13 __________________________________________ ) (Petitioner/Guardian Ad Litem) ) 14 STATE OF OREGON ) 15 ) ss. County of Marion ) 16 I, __________________________, being first duly sworn, do hereby declare and say: 17 To the best of my knowledge and belief, the other parent of this child is: ___________________. 18 The child has not lived with the other parent and the other parent has not contributed, or19 tried to contribute to the childs support at any time since the childs birth. 20 _______________________________21 Petitioner/Guardian Ad Litem 22 SIGNED AND SWORN to before me on ______________________________. 23 ______________________________________________________24 Deputy Court Administrator/Notary Public for the State of ______ My commission expires:__________________________________ 25 26 27 28 AFFID AV IT FOR MOTION TO WAIV E NOTICE TO OTHE R PA REN T - Page 1 of 2 FC(3/1/04)(Form9M /1)>>>> 2 1 Submitted by: 2 ______________________________________ 3 Attorney/Petitioners Name Bar No. (if any) 4 _____________________________________ Address 5 ______________________________________ 6 City State Zip Phone No. 7 ______________________________________ Trial Attorney if other than above Bar No. 8 9 10 Certificate of Document Preparation11 If this document was not completed by an attorney, I hereby certify that the following statements are true: (check all boxes and complete all blanks that apply)12 A. G I selected this document for myself, and I completed it without paid assistance. B. G I paid or will pay money to _________________ for assistance in preparing this13 form/document 14 __________________________ Signature15 16 17 18 19 20 21 22 23 24 25 26 27 28 AFFID AV IT FOR MOTION TO WAIV E NOTICE TO OTHE R PA REN T - Page 2 of 2 FC(3/1/04)(Form9M /1)