Free STATE OF MINNESOTA DISTRICT COURT - Minnesota

State of Minnesota
County
Select County

District Court
Judicial District: Court File Number: Case Type: Dissolution

In the Matter of the Application of:

First Middle Last

Felony Notification Affidavit
For a change of name to:

First Middle Last

State of Minnesota County of
(County where Affidavit signed)

) ) SS )

Application for Name Change Application for a Marriage License with Name Change Application for Name Change Pursuant to a Marriage Dissolution A notice pursuant to Minn. Stat. §259.13 was served upon the prosecuting authority that obtained the day of and which proof of service has been filed with the conviction on the court on the day of . If the prosecuting authority who obtained the conviction is from another state other than Minnesota or federal jurisdiction a notice was served also on the Minnesota Attorney General at 102 State Capitol day of Building, St. Paul, MN 55155 and which proof of service has been filed with the court on the . In reference to the above a period of 30 days has passed since notifying the prosecuting authority. A person who knowingly violates Minnesota Stat. 259.13 is guilty of a gross misdemeanor. Dated: Signature
(Sign only in front of notary public or court administrator)

Name: Subscribed and sworn to before me this ___ day of _________________, _____ ________________________________
Notary Public \ Deputy Court Administrator

(print)

Street Address City/State/Zip Telephone

DIV106

State

ENG

Rev 5/08-D

www.mncourts.gov/forms

Page 1 of 1