Application For Change Of Name For A Minor Child Form - Arizona
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FOR CLERK USE ONLY
Person Filing Document:
____________________________________
Mailing Address:
____________________________________
City, State, Zip Code:
____________________________________
Daytime/Evening Phone Number: ____________________________________
ATLAS Number (if applicable):
____________________________________
Attorney Bar Number (if applicable): __________________________________
Represented by
Self or
by Attorney
SUPERIOR COURT OF ARIZONA
IN MOHAVE COUNTY
Case Number: ________________________
APPLICATION FOR CHANGE OF
In the Matter of:
NAME FOR A MINOR CHILD
(A.R.S. §12-601)
A Minor
STATEMENTS TO THE COURT, UNDER OATH OR AFFIRMATION
1. INFORMATION ABOUT ME, THE APPLICANT
_____________________________
________________________ _________________________________
(First)
(Middle)
(Last)
Applicant’s Address:______________________________________________________________________
County of Residence:__________________________________
Date of Birth:___________________ Place of Birth: ____________________________________________
(Month / Day / Year)
(City / State / Nation)
2. INFORMATION ABOUT THE MINOR FOR WHOM THIS NAME CHANGE IS REQUESTED:
Name as it appears on the Birth Certificate:
_____________________________
________________________ __________________________________
(First)
(Middle)
(Last)
Address Same as Applicant, or____________________________________________________
Relation to Applicant:_______________________
County of Residence:____________________________
Date of Birth:___________________
Place of Birth:_______________________________________________
(Month / Day / Year)
(City / State / Nation)
New Name Requested:
_____________________________
________________________ __________________________________
(First)
(Middle)
(Last)
3.
I ASK THAT THE BIRTH RECORDS BE CHANGED TO REFLECT THE NEW NAME LISTED ABOVE.
Page 1 of 2
Revised: 4/13/2011
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