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Fill and Sign the Application for Change of Name of Adult Clermont County Form

Fill and Sign the Application for Change of Name of Adult Clermont County Form

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PROBATE COURT OF __________________ COUNTY, OHIO IN RE: CHANGE OF NAME OF (Present Name) To (Name Required) Case No. AUTHORIZATION TO RELEASECONFIDENTIAL INFORMATION Name LastFirstMiddleDate of Birth Social Security Number I hereby authorize the release of all confidential records and information concerning me to any officer or agent of the __________________ County Probate Court for the purpose of my application for change of name. I understand that this disclosure is not mandatory to obtain a name change. Further, I understand that this document will become part of the Probate Court’s permanent public record. ____________________________________ ____________________________________WitnessDateSignature____________________________________ ____________________________________WitnessDateSignature AUTHORIZATION TO RELEASECONFIDENTIAL INFORMATION

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