STATE OF TENNESSEE COUNTY OF SHELBY AFFIDAVIT FOR NAME CHANGE The undersigned, having petitioned for a name change, hereby makes oath, as required by T. C. A. § 29-8-101 (b) that: 1. I have never been convicted of First or Second Degree Murder. 2. I have never been convicted of any offense, the commission of which requires registration pursuant to the “Sexual Offender Registration and Monitoring Act” found in Tennessee Code Annotated, Title 40, Chapter 39. ________________________________ Name ________________________________ Address ________________________________ City, State, Zip Code ________________________________ Phone Number Sworn to and subscribed before me this _________ day of ___________________, ____________. Kenny W. Armstrong, Clerk & Master By____________________________ Deputy Clerk American LegalNet, Inc. www.USCourtForms.com