Free PC52.pmd - Michigan

Approved, SCAO

JIS CODE: OCN

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

FILE NO. ORDER FOLLOWING HEARING ON PETITION TO CHANGE NAME

COUNTY

In the matter of the name change of
Present first name(s), middle name(s), and last name(s) (type or print)

to
Requested new first name(s), middle name(s), and last name(s) (type or print)

1. Date of Hearing: THE COURT FINDS: 2. A petition for name change has been filed. 3. Notice of hearing was given by publication.

Judge:

Bar no.

4. Each person for whom a name change is sought has been a resident of the county for at least one year. 5. The court has received the required criminal record report(s) from the Michigan Department of State Police. 6. 7.
Name(s) (type or print)

has a criminal record. is is not

a. The request for name change of Name(s) (type or print) made with fraudulent intent. b. The request for name change of Name(s) (type or print) made with fraudulent intent.

8. The petitioner, having legal custody, requests the name change of a minor. The noncustodial parent has consented to the name change. 9. The petitioner requests the name change of a minor. The custodial parent has consented to the name change. The noncustodial parent was given notice of the hearing. a. The noncustodial parent has had the ability to visit, contact, or communicate with the minor but has regularly and substantially failed or neglected to do so for the past two years, and a support order has been entered, and the noncustodial parent has failed to substantially comply with the order or for a period of two years or more before the filing of the petition for name change. a support order has not been entered and the noncustodial parent, having the ability to support or assist in supporting the child, has failed or neglected to provide regular and substantial support for two years or more before the filing of the petition for name change. b. The noncustodial parent has been convicted of child abuse (MCL 750.136b), criminal sexual conduct (MCL 750.520b, 750.520c, 750.520d, or 750.520e), or assault with intent to commit criminal sexual conduct (MCL 750.520g), and the child or a sibling of the child was the victim. 10. 11. The minor(s) under the age of 14 has/have stated a preference to a name change. The minor(s) is/are not of sufficient age to express a preference to a name change. (PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only

PC 52 (9/08)

ORDER FOLLOWING HEARING ON PETITION TO CHANGE NAME

MCL 333.2872, MCL 711.1, MCR 5.781

IT IS ORDERED: 12. The name(s) of the following person(s) is/are changed: FROM

TO

DATE OF BIRTH
month, day, year month, day, year month, day, year month, day, year month, day, year month, day, year

13. The State Registrar shall create a new live birth certificate for

Name

that does not disclose the name at birth and shall seal the original certificate. 14. The request to change the name of
Name

is denied.

15. The request is denied and the petition is dismissed.

Date

Judge

Attorney name (type or print) Address City, state, zip

Bar no.

Telephone no.

NOTE TO PETITIONER: You must provide this order to the State Registrar if you want to change your birth certificate.

Note to Clerk: Pursuant to MCL 711.1(3), if the court enters an order to change the name of a person who has a criminal record, the court shall forward the order to the Criminal Records Division of the Michigan State Police and to one or more of the following: · The Department of Corrections if the person named in the order is in prison or on parole or has been imprisoned or released from parole in the immediately preceding two years. The sheriff of the county in which the person named in the order was last convicted if the person was incarcerated in a county jail or released from a county jail within the immediately preceding two years. The court that has jurisdiction over the person named in the order if the person named in the order is under the jurisdiction of the family division of the circuit court.

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