Free Consent of Minor to Name Change - 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 (No Attorney) OR by Attorney

For Clerk's Use Only

SUPERIOR COURT OF ARIZONA IN MOHAVE COUNTY
In the Matter of Case Number:

_____________________________
A Minor

CONSENT OF MINOR TO NAME CHANGE
(if minor is 14 or older)

REQUIRED INFORMATION FROM MINOR, UNDER OATH OR AFFIRMATION 1. INFORMATION ABOUT ME:
Name on Birth Certificate: First: ______________________ Middle: ____________________ Last: _____________________

Address:___________________________________________________________________________ Telephone: _________________________________________________________________________ Date of Birth: ________________________ Month Place of Birth: _______________________ City ______________________ Date ______________________ State _________________ Year _________________ Nation

I am the minor who is the subject of this name change request. I am at least 14 years of age.

2.

I have read the Application for Name Change and consent to changing my legal name to: First: ______________________ Middle: ____________________ Last: _____________________

3.

I waive notice of all further proceedings in this matter.

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

10/27/2006