Application For Change Of Name For An Adult - Superior Court Of Arizona In Mohave County
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For Clerk’s Use Only
Name of Person Filing:
____________________________________
Mailing Address:
____________________________________
City, State, Zip Code:
____________________________________
Daytime/Evening Phone Number:
____________________________________
ATLAS Number (if applicable)
____________________________________
Attorney Bar Number (if applicable)
____________________________________
Represented by
Self or
by Attorney
SUPERIOR COURT OF ARIZONA IN MOHAVE COUNTY
Case Number: __________________________
APPLICATION FOR CHANGE OF
In the Matter of:
NAME FOR AN ADULT
(A.R.S. §12-601)
_________________________________
Current Name of Applicant
STATEMENTS TO THE COURT, UNDER OATH OR AFFIRMATION
1.
INFORMATION ABOUT ME, THE APPLICANT
A. Name on Birth Certificate (Applicant) or
Current Legal Name
___________________________ ___________________________
___________________________
First
Middle
Last
Date of Birth:
_______________________________________
Place of Birth: _______________________________________
County of Residence:___________________________________
2.
REQUESTS TO THE COURT:
I ask that my name be changed to:
___________________________ ___________________________
___________________________
First
Middle
Last
I ask that the birth records be changed to reflect the new name listed above.
3.
STATEMENTS TO THE COURT REQUIRED BY ARIZONA LAW (A.R.S. §12-601 (C))
(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 person
for whom the name change is requested.
b.
I understand and acknowledge that this change of name, if granted, will not release me 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.
Page 1 of 3
Revised: 1/4/2010
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