_____________________________ (Name) _____________________________ (Address) _____________________________ (City) _____________________________ (Telephone) ____________ DISTRICT COURT, ______________________ COUNTY, UTAH COURT’S ADDRESS: _____________________________________________________ IN THE MATTER OF THE NAME CHANGE OF: RETURN OF SERVICE ______________________________,. (minor’s name) Case No. ____________________ A minor. Judge _______________________ ____________________________________, Affiant, being first sworn and under oath, (Name of person who served Summons and Petition) deposes and says: 1.Affiant resides in ______________________ County, State of ______________. (name of county) (name of state) Affiant is more than 18 years old and does not have an interest in this action. 2. Affiant received the Summons and Petition for this action on __________________. (date) 3.Affiant personally served Respondent with the Summons and Petition in Minor’s Name Change: Return of Service, p. 1 Approved: November 19, 2004 American LegalNet, Inc. www.USCourtForms.com _______________________ County, on ___________________, at (name of county) (date) _________________________________________________________ . At the time of service, (address where served) Affiant knew that the person served was the Respondent in this action. 4. At the time of service of the Summons and Petition, Affiant also served Respondent personally with the following additional documents: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 5.At the time of service, Affiant wrote the date and place of service on the copy of the Summons left for the person being served. Affiant also signed Affiant’s name and added Affiant’s official title, if an officer, to the Summons. DATED: _________________________ ____________________________________ Affiant (Person serving the Summons) NOTARY CLAUSE __________________________, Affiant, is personally known to me or presented satisfactory proof of identity. After being sworn and while under oath, Affiant stated that he or she was acting voluntarily, had read and understood the preceding document, and that the contents were true. Affiant then signed the document in my presence. Signed on _________________, 20____. X_________________________________________ Notary Public/Court clerk (Notary Seal) Minor’s Name Change: Return of Service, p. 2 Approved: November 19, 2004 American LegalNet, Inc. www.USCourtForms.com