Application For Change Of Name For A Family - Superior Court Of Arizona In Mohave County Page 2
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4Case No.________________________________
C.
Name on Birth Certificate or
Current Legal Name:
___________________________ ___________________________
___________________________
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)
REQUESTS NAME BE CHANGE TO:
___________________________ ___________________________
___________________________
First
Middle
Last
If you wish to include more people in this application, please attach another sheet of paper. List for
each person their current name as on birth certificate, address, date of birth, county of residence, place
of birth, relationship to Applicant, and the new name requested.
2.
REASON FOR THIS REQUEST FOR CHANGE OF LEGAL NAME
I request that the legal names be changed as listed above for the following reasons:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
STATEMENTS TO THE COURT REQUIRED BY ARIZONA LAW (A.R.S. §12-601 (C))
3.
(Check the boxes that indicate a true statement) (For “d,” explain.)
A.
I submit this application solely for the benefit and in the best interests of the persons for whom the
name change is requested.
B.
I understand and acknowledge that this change of name, if granted, will not release me or
anyone for whom a change of name is requested on this Application from any obligations
incurred or harm any rights of property or action in any previous name.
C.
I am not knowingly requesting this change of name to that of another individual for the
purpose of committing or furthering any offense of theft, forgery, fraud, perjury, organized
crime or terrorism or any other offense involving false statements.
D.
Have you or any adult listed above ever been convicted of a felony?
Yes
No
If “yes,” list all felony convictions on the next page.
Page 2 of 4
Revised: 1/11/2010
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