Application For Change Of Name Of Adult - Ohio Probate Court

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PROBATE COURT OF ________________ COUNTY, OHIO
IN RE: CHANGE OF NAME
OF__________________________________________________
(Present Name)
TO ________________________________________________________________________
(Name Requested)
CASE NO. _______________________
APPLICATION FOR CHANGE OF NAME OF ADULT
[R.C. 2717.01]
The applicant states that the applicant is an adult and has been a bona fide resident of ______________ County,
Ohio, for at least one year immediately prior to the filing of this application.
The applicant requests a change of name from ____________________________________________________
to_________________________________________________________________________________________
for the following reason: _______________________________________________________________________
___________________________________________________________________________________________
_________________________________________________________________________________________.
The applicant states that the applicant will cause notice of the application to be published once in a newspaper of
general circulation in this county at least thirty (30) days before the hearing on this application.
The applicant states that the applicant
1) _____
has
has not been convicted of, pleaded guilty to, or been adjudicated a delinquent child for identity
fraud.
initials
2) _____
has a
has no duty to comply with R.C. 2950.04 or R.C. 2950.041 because the applicant was
convicted of, pled guilty to, or was adjudicated a delinquent child for having committed a sexually
initials
oriented offense or a child-victim oriented offense.
______________________________________
_____________________________________
Attorney for Applicant
Applicant’s Signature
______________________________________
_____________________________________
Typed or Printed Name
Typed or Printed Name
______________________________________
_____________________________________
Address
Address
______________________________________
______________________________________
City
State
Zip
City
State
Zip
______________________________________
_____________________________________
Telephone Number (include area code)
Telephone Number (include area code)
Attorney Registration No. __________________
FORM 21.0 - APPLICATION FOR CHANGE OF NAME OF ADULT
Amended: January 1, 2013
Discard all previous versions of this form

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