Fill and Sign the Application for Change of Name for a Minor Child Ars 12 601 Cvncm11f Application for Change of Name for a Minor Child Ars 12 Form

Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: Lawyer’s Bar Number: Representing Self, without a Lawyer or Attorney for Petitioner OR Respondent SUPERIOR COURT OF ARIZONA IN _____________ COUNTY Case Number: In the Matter of: A PPLICATION FOR CHANGE OF NAME FOR A MINOR CHILD ( ARS 12-601) A Minor STATEMENTS TO THE COURT, UNDER OATH OR AFFIRMATION 1. I NFORMATION ABOUT ME, THE APPLICANT (First) (Middle) (Last) Applicant’s Address is Listed Above. County of Residence: Date of Birth: Place of Birt h: (Month / Day / Year) (City, State, Nation) 2.INFORMATION ABOUT THE MINOR FOR WHOM THI S NAME CHANGE IS REQUESTED: Name as it appears on the Birth Certificate: (First) (Middle) (Last) Address Same as Applicant, or: Relation to Ap plicant: County of Residence: FOR CLERK USE ONLY © Superior Court of Ar izona CVNCM11f 050115 ALL RIGHTS RESERVED Use current version Page 1 of 2 Case No. Date of Birth: Place of Birth: (Month / Day / Year) (City, State, Nation) New Name Requested: (First) (Middle) (Last) 3.I ASK THAT THE BIRTH RECORDS BE CHANGED TO REFLECT THE NEW NAME LISTED ABOVE. 4. I REQUEST THAT THE N AME BE CHANGED FOR THE FOLLOWING REASONS : A DDITIONAL STATEMENTS I understand that this name change does not establish paternity and will not cause a father’s name to be added to a birth certificate. T his application is made solely for the best interest of the minor child named above. It will not release the person from any obligations incurred or harm any rights of property or action in any original name. UNDER OATH OR BY AFFIRMATION I swear or affirm under penalty of perjury that the contents of this document are true and correct to the best of my knowledge and belief. Date Petitioner’s Signature Printed Name STATE OF COUNTY OF Subscribed and sworn to or affirmed before me this: by (date) . (notary seal) Deputy Clerk or Notary Public © Superior Court of Ar izona CVNCM11f 050115 ALL RIGHTS RESERVED Use current version Page 2 of 2