Free Application for Change of Name for a Minor Child - Arizona

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Person Filing Document: ____________________________________ Mailing Address: ____________________________________ City, State, Zip Code: ____________________________________ Daytime/Evening Phone Number: ____________________________________ ATLAS Number (if applicable): ____________________________________ Attorney Bar Number (if applicable(:___________________________________ Represented by Self or by Attorney

FOR CLERK USE ONLY

SUPERIOR COURT OF ARIZONA IN MOHAVE COUNTY
Case Number:

In the Matter of:

APPLICATION FOR CHANGE OF NAME FOR A MINOR CHILD

A Minor

STATEMENTS TO THE COURT, UNDER OATH OR AFFIRMATION
1. INFORMATION ABOUT ME, THE APPLICANT _____________________________ (First) ________________________ ________________________________ (Middle) (Last)

Applicant's Address:______________________________________________________________________ County of Residence:__________________________________ Date of Birth:___________________ Place of Birth:_____________________________________________ (Month / Day / Year) (City / State / Nation)

2. INFORMATION ABOUT THE MINOR FOR WHOM THIS NAME CHANGE IS REQUESTED: Name as it appears on the Birth Certificate: _____________________________ (First) ________________________ _________________________________ (Middle) (Last)

Address Same as Applicant, or:_____________________________________________________________ Relationship to Applicant:: _______________________ County of Residence: __________________

Date of Birth: ________________________ Place of Birth: _____________________________________ (Month / Day / Year) (City, State, Nation) New Name Requested: _____________________________ (First) 3. ________________________ ________________________________ (Middle) (Last)

I ASK THAT THE BIRTH RECORDS BE CHANGED TO REFLECT THE NEW NAME LISTED ABOVE.

10/16/2006

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Case No._____________________________

4. I REQUEST THAT THE NAME BE CHANGED FOR THE FOLLOWING REASONS: _________________________________________________________________________________________ _________________________________________________________________________________________

ADDITIONAL STATEMENTS
I understand that this name change does not establish paternity and will not cause a father's name to be added to a birth certificate. This application is made solely for the best interest of the minor child named above. It will not release the person from any obligations incurred or harm any rights of property or action in any original name.

OATH OR AFFIRMATION OF APPLICANT
STATE OF ARIZONA ) ) ss COUNTY OF MOHAVE )

The contents of this document are true and correct to the best of my knowledge and belief. Signature: _________________________________________ Date: __________________________

Sworn to or affirmed before me on this _________________ day of __________________, 20____________ By: ____________________________________ My Commission Expires: ___________________ ____________________________________ Notary Public or Deputy Clerk

10/16/2006

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