Free Form #5M - Oregon

1 2 3 4 5 6 7 8 9 10 __________________________________________ 11 12 13 14 15 16 17 18 STATE OF ___________ 19 County of ____________ 20 21 22 23 24 25 26 27 28
CONSENT OF MINOR OVER 14 FOR CHANGE OF NAME - Page 1 of 2 FC(3/1/04)(Form 5M)

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE THIRD JUDICIAL DISTRICT

In the Matter of the Change of Name of: __________________________________________ __________________________________________ (Present Name(s) of Minor Child/ren)

__________________________________________ (Proposed Name(s) of Minor Child/ren) __________________________________________ (Petitioner/Guardian Ad Litem)

) ) ) ) ) ) ) ) ) ) ) ) ) )

Case No: __________ CONSENT OF MINOR OVER 14 FOR CHANGE OF NAME

I hereby consent to the petition to change my name from ________________________ to ___________________________, and waive further notice in this proceeding. _______________________________ Signature (present name) ) ) ss. )

The above named ________________________ personally appeared before me and acknowledged the foregoing instrument to be his/her voluntary act and deed this _____ day of ___________________, _________.

_____________________________________________________ Deputy Court Administrator/Notary Public for the State of ______ My commission expires:_________________________________

1 Submitted by: 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
CONSENT OF MINOR OVER 14 FOR CHANGE OF NAME - Page 2 of 2 FC(3/1/04)(Form 5M)

______________________________________ Attorney/Petitioner's Name Bar No. (if any) ______________________________________ Address ______________________________________ City State Zip Phone No. ______________________________________ Trial Attorney if other than above Bar No. Certificate of Document Preparation If this document was not completed by an attorney, I hereby certify that the following statements are true: (check all boxes and complete all blanks that apply) A. G I selected this document for myself, and I completed it without paid assistance. B. G I paid or will pay money to _________________ for assistance in preparing this form/document __________________________ Signature