State of Minnesota
In the Matter of the Application of (current name):
First Middle Last
Judicial District: Court File Number: Case Type: Name Change
For a change of name to (new name):
Application for Name Change (Minn. Stat. § 259.10)
The undersigned applicant sworn/affirmed on oath states that: 1. 2. This application is made in good faith, without intent to defraud or mislead. All persons who are asking to have their names changed on this application have lived in the State of Minnesota for at least six months immediately prior to the date of this application, and now live at:
No. City/Town State Zip Street County
Name of applicant and date of birth: Name of applicant's spouse and date of birth: does does not include spouse. This application Name(s) of minor child(ren) and date(s) of birth: This application does not include minor child(ren) listed above. This application includes the following minor child(ren) listed above:
6. The name and address of the non-applicant parent is:
Applicant requests: To have his/her name changed to To have the name of his/her spouse changed to To have the names of his/her minor child(ren) changed to
The criminal history of the following parties included in this application is: ____________________________________ _________________________________________________________________________________________________ The following parties included in this application have been convicted of a felony:
List name, date of offense, and state. If no criminal history, write "No criminal history." If no felony convictions, write "No felony convictions."
Legal description of lands in the State of Minnesota upon which the following have a claim, interest, or lien: (Provide the legal description and attach additional pages if necessary) Applicant Spouse Child(ren)
Page 1 of 2
I am currently involved in a victim or witness protection program.
I am an inmate in a correctional facility, and have attached the Inmate Affidavit for Name Change.
12. Other: .
Date: Co-applicant's Signature (Spouse) Applicant's Signature Minor's Signature (14 or older)
State of Minnesota
, being duly sworn on oath, says that he/she has read the foregoing application and knows the contents thereof, and that the same is true of his/her own knowledge. Sworn/affirmed before me Date:
Deputy Court Administrator / Notary Public
My Commission Expires
Page 2 of 2