Form 21.0 - Application For Change Of Name Of Adult
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1PROBATE COURT OF WOOD COUNTY, OHIO
David E. Woessner, Judge
In the Matter of the CHANGE OF NAME OF:_______________________________________________
(Present Name)
To________________________________________________________________________________
(Name Requested)
Case No. ______________________________
APPLICATION FOR CHANGE OF NAME OF ADULT
(RC 2717.01)
The Applicant states that the Applic ant is an adul t and has been a bona fide resident of Wood County,
Ohio, for at least one year immediately prior to the filing of this Applicati on. 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 swears that he/she:
has
has not been convicted of, plead guilty to, or been
adjudicated a delinquent child for committing identity fraud; and
does
does not have a duty to
comply with ORC 2950.04 or 2950.041 due to being convicted of, pleading guilty to, or being adjudicated
a delinquent child for having committed a sexually oriented offense or child-victim oriented offense.
The Applicant wishes to have his or her birth certificate changed to reflect the new name:
Yes
No
Attorney for Applicant
Applicant
Typed or Printed Name
Typed or Printed Name
Address:
Address:
Phone Number (include area code)
Phone Number (include area code)
Attorney Registration Number
Sworn to before me and subscribed in my presence this ________ day of ___________________________, _____________
_____________________________________________________
Notary Public Signature
____________________________________________________
Printed Name and Commission Expiration Date
21.0 Application for Change of Name of Adult
May 2014
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