Free Consent of Parent to Name Change of a Minor Child and Waiver of Notice - Arizona

Reset Name of Person Filing: ____________________________________ 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 MOHAVE COUNTY
In the Matter of Case Number:

CONSENT OF PARENT TO NAME CHANGE OF A MINOR CHILD AND WAIVER OF NOTICE
a Minor

REQUIRED INFORMATION FROM PARENT, UNDER OATH OR AFFIRMATION: 1. INFORMATION ABOUT ME:
Name: _______________________________________________________________________________ Address: _____________________________________________________________________________ Telephone: _________________________________ Date of Birth: _______________________ Month Place of Birth:_______________________ City I am the natural I am the adoptive MOTHER or MOTHER or ______________________ Date ______________________ State ___________________ Year ___________________ Nation

FATHER of the minor child named above. FATHER of the minor child named above.

2.

I have read the Application for Name Change and consent to changing the child's 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

10/23/2006