Application For Change Of Name For A Minor Child Form - Arizona Page 2

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Case No._____________________________
4. I REQUEST THAT THE NAME BE CHANGED FOR THE FOLLOWING REASONS:
_________________________________________________________________________________________
_________________________________________________________________________________________
ADDITIONAL STATEMENTS
I understand that this name change does not establish paternity and will not cause a father’s name to be
added to a birth certificate.
This application is made solely for the best interest of the minor child named above. It will not release the
person from any obligations incurred or harm any rights of property or action in any original name.
OATH OR AFFIRMATION OF APPLICANT
STATE OF ARIZONA
)
) ss
COUNTY OF MOHAVE )
I affirm under penalty of perjury the contents of this document are true and correct to the best of my knowledge
and belief.
Signature: _________________________________________
Date: __________________________
Sworn to or affirmed before me on this _________________ day of __________________, 20____________
By: ____________________________________
My Commission Expires: ___________________
____________________________________
Notary Public or Deputy Clerk
Page 2 of 2
Revised: 4/13/2011

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