State Of Minnesota District Court Application For Name Change And/or Additional Relief
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1
2State of Minnesota
District Court
County
Judicial District:
Court File Number:
Case Type:
Name Change
In the Matter of the Application of (current name):
First
Middle
Last
First
Middle
Last
First
Middle
Last
Application for Name Change
And / Or Additional Relief
For a change of name to (new name):
(Minn. Stat. § 259.10)
First
Middle
Last
First
Middle
Last
First
Middle
Last
The undersigned applicant sworn/affirmed on oath states that:
1. This application is made in good faith, without intent to defraud or mislead.
2. 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.
Street
City/Town
State
Zip
County
3. Name of applicant and date of birth:
4. Name of applicant’s spouse and date of birth:
This application
does
does not include spouse.
5. 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:
The non-applicant parent is not known and his/her name is not shown on the birth certificate.
7. 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
NAM102
State
ENG
Rev 3/10
Page 1 of 2
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