Instructions For Change Of Name (Adults Only) Page 3
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3I _________________________________________ authorize the Madison
County Sheriff’s Department to release my criminal background information to
Madison County Probate Court.
__________________________________________________
PROBATE
Print Name
__________________________________________________
Any other names that you have used (maiden, married)
__________________________________________________
Name after legal name change (in full)
__________________________________________________
Date of Birth
__________________________________________________
Social Security Number
__________________________________________________
______________________
Applicant Signature
Date
----------------------------------------------------------------------------------------------------------------------------------
DO NOT WRITE BELOW THIS LINE
History of Criminal Activities:
Date
Offense
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________
Agency
_________________________________________
_________________________
Signature/Title
Date
***NOT VALID AFTER THIRTY (30) DAYS***
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