Free Microsoft Word - NAM105 - Minnesota

State of Minnesota
County
Select County

District Court
Judicial District: Court File Number: Case Type: Name Change

In the Matter of the Application of:
First Middle Last

For a change of name to:

Inmate Affidavit for Name Change (Minn. Stat. § 259.12)
Last

First

Middle

STATE OF MINNESOTA

) ) COUNTY OF _________________)
(County where Affidavit signed)

ss.

I, under oath:

, the applicant in this matter, make the following statement

I am currently an inmate confined in a correctional facility, as defined in section 241.021, subdivision 1, clause (5). I have not at any time during my confinement requested a name change under section 259.10, other than this request. The reason I am seeking a name change is:

I request the court to issue its Order Granting Name Change.

Dated:
Signature (Sign only in front of notary public or court administrator.)

Name: Subscribed and sworn to before me Date:
Notary Public \ Deputy Court Administrator

Address: . City/State/Zip: Telephone:

NAM105

State

ENG

Rev 8/08

www.mncourts.gov/forms

Page 1 of 1