Fill and Sign the Felony Notification Affidavit for Name Change Minnesota Form

State of Minnesota District Court County Judicial District: Court File Number: Case Type: Dissolution without Children In Re the Application of: First Middle Last Name Felony Notification Affidavit For a change of name to: First Middle Last Name STATE OF MINNESOTA ) COUNTY OF ) SS (County where Affidavit signed) □ Application for Name Change □ Application for a Marriage License with Name Change □ Application for Name Change Pursuant to a Marriage Dissolution A notice pursuant to Minn. Stat. §259.13 was served upon the prosecuting authority that obtained the conviction on the day of and which proof of service has been filed with the court on the day of . If the prosecuting authority who obtained the conviction is from another state other than Minnesota or federal jurisdiction a notice was served also on the Minnesota Attorney General at 102 State Capitol Building, St. Paul, MN 55155 and which proof of service has been filed with the court on the day of . In reference to the above a period of 30 days has passed since notifying the prosecuting authority. A person who knowingly violates Minnesota Stat. 259.13 is guilty of a gross misdemeanor. I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116. Dated: Signature Name: Street Address: City/State/Zip: DIV810 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 2 Telephone: ( ) E-mail address: DIV810 State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 2