Fill and Sign the Case Number Cv 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 In the Matter of: Case Number: CV APPLICATION FOR CHANGE OF NAME FOR AN ADULT Current Name of Applicant (A.R.S. § 12-601) INFORMATION ABOUT ME, THE APPLICANT 1. BIRTH NAME: on your original registered state Birth Record ( Certificate ): First Middle Last Date of Birth: City of Birth: County of Birth : 2. CURRENT LEGAL NAME: First Middle Last Current Address: Current City of Residence: Current State of Residence & Zip Code: This is my married name, and that of my Current Spouse Past Spouse For Clerk’s Use Only © S uperior Court of A rizona CVNC11f - 060116 ALL RIGHTS RESERVED Page 1 of 4 Case No. _________________ 3. OTHER NAMES: (Check all that Apply) I was previously married – o From ______________ to _______________ and used the following name: (Month, Year) (Month, Year) First Middle Last I was previously married – o From ______________ to _______________ and used the following name: (Month, Year) (Month, Year) First Middle Last I changed my name – from this name: _________________________________ o W hen? ______________ to _______________ and used the following name: (Month, Year) (Month, Year) First Middle Last I changed my name – from this name: _________________________________ o W hen? ______________ to _______________ and used the following name: (Month, Year) (Month, Year) First Middle Last I have used the following alias :_________________________________ o W hen? ______________ to _______________ I used the following name: (Month, Year) (Month, Year) First Middle Last I have used the following alias: _________________________________ o W hen? ______________ to _______________ I used the following name: (Month, Year) (Month, Year) First Middle Last CVNC11f - 060116 ALL RIGHTS RESERVED © S uperior Court of A rizona Page 2 of 4 Case No. _________________ REQUESTS TO THE COURT 1. I ASK THAT MY NAME BE CHANGED TO: First Middle Last 2. I ask that the birth records be ordered changed to reflect the new name requested above. STATEMENTS TO THE COURT (REQUIRED BY ARIZONA LAW (A.R.S. § 12 -601(C)) ) Under Penalty of Perjury, I state the follow ing as true: (Check the boxes that indicate a true statement.) (For “ 4”, explain. ) 1. I submit this application solely for the benefit and in the best interes ts of the person for whom the name change is requested. 2. I understand and acknowledge that this change of name, if gra nted, will not release me from any obligations incurred or harm any rights of property or action in any previous name. 3. I am not knowingly requesting this change of n ame to that of another individual for the purpose of committing or furthering any offense of theft, forgery, fraud, p erjury, organized crime or terrorism or any other offense involving false statements. 4. I request this name change be cause: (Explain ) 5. Have you ever been convicted of a felony? Yes No If “Yes ,” all felony convictions are listed below. Felony Case No. County & State Sentence Date of Conviction 1 2 3 4 5 Is there anything regarding your felony conviction(s) that you woul d like to bring to the Court’s attention? (Optional) CVNC11f - 060116 ALL RIGHTS RESERVED © S uperior Court of A rizona Page 3 of 4 Case No. _________________ 6. Are there any criminal charges (felony or misdemeanor) pending against you at this time? Yes No If “Yes ,” all pending charges are listed below: Pending Charges Name of Court or City & State Case No. 1 2 3 4 5 Is there anythi ng regarding your pending criminal charges that you would lik e to bring to the Court’s attention? (Optional) 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 CVNC11f - 060116 ALL RIGHTS RESERVED © S uperior Court of A rizona Page 4 of 4