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 __________________________________________ ) ) 9 __________________________________________ ) Case No: __________ (Present Name(s) of Minor Child/ren) ) 10 ) CONSENT OF __________________________________________ ) MINOR OVER 1411 ) FOR CHANGE OF NAME __________________________________________ ) 12 (Proposed Name(s) of Minor Child/ren) ) ) 13 __________________________________________ ) (Petitioner/Guardian Ad Litem) ) 14 15 I hereby consent to the petition to change my name from ________________________ to16 ___________________________, and waive further notice in this proceeding. 17 _______________________________ Signature (present name) 18 STATE OF ___________ ) 19 ) ss. County of ____________ ) 20 The above named ________________________ personally appeared before me and 21 acknowledged the foregoing instrument to be his/her voluntary act and deed this _____ day of ___________________, _________. 22 23 _____________________________________________________ 24 Deputy Court Administrator/Notary Public for the State of ______ My commission expires:_________________________________ 25 26 27 28 CONSENT OF MINOR OVER 14 FOR CHANGE OF NAME - Page 1 of 2 FC(3/1/04)(Form 5M) >>>> 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 Certificate of Document Preparation 10 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) 11 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 this12 form/document 13 __________________________ Signature 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 CONSENT OF MINOR OVER 14 FOR CHANGE OF NAME - Page 2 of 2 FC(3/1/04)(Form 5M)