STATE OF TENNESSEE COUNTY OF SHELBY AFFIDAVIT FOR NAME CHANGE OF MINOR BY NATURAL MOTHER OR FATHER AND NEXT FRIEND 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. Relationship to Minor ________________________________ 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