_____________________________ (Name) _____________________________ (Address) _____________________________ (City) _____________________________ (Telephone) ____________ DISTRICT COURT, ______________________ COUNTY, UTAH COURT’S ADDRESS: _____________________________________________________ IN THE MATTER OF THE NAME CHANGE OF: DEPARTMENT OF CORRECTIONS CERTIFICATION REGARDING SEX OFFENDER REGISTRY ______________________________, (petitioner’s name) Case No. ____________________ Petitioner. Judge _______________________ Notice to petitioner: This form must be completed and attached to the Petition for Name Change before it is filed with the court. To obtain the necessary certification, fill in the required identification information in the chart below, and then mail the form and a self-addressed, stamped envelope to the following address: S.O.R.P. / 14717 Minuteman Drive / Draper, UT 84020. Petitioner’s name Date of birth Driver license number (This section to be completed by S.O.R.P. personnel) I certify that I searched Utah’s Sex Offender Registry for the individual identified above: The results of this search were: ‫ ڤ‬positive ‫ ڤ‬negative ‫ ڤ‬other _____________________________________ DATED: ______________________ Name Change: D.O.C. Certification re Sex Offender Registry ____________________________________ Sex Offender Registration Program Personnel UTAH DEPARTMENT OF CORRECTION Approved: November 19, 2004 American LegalNet, Inc. www.USCourtForms.com