Fill and Sign the For a Change of Name to New Name of Minors Form

NAM202 State ENG Re v 9/15 www.mncourts.gov/forms Page 1 of 2 State of Minnesota District Court County Judicial District: Court File Number: Case Type: Name Change □ Interpreter Requested Language In the Matter of the Application of: First Middle Last On Behalf of (current name of minor(s)): Application for Name Change Firs t Middle Last of a Minor (Minn. Stat. § 259.10) First Middle Last For a change of name to (new name of minor(s)): First Middle Last First Middle Last STATE OF MINNESOTA ) ) SS COUNTY OF ) The undersigned applicant states that: 1. This application is made in good faith, without intent to defraud or mislead. 2. The minor child(ren) whose name(s) are sought to be changed on this application have lived in the State of Minnesota for at least six months immediately prior to the date of this application, and now live at: No. Street City/Town State Zip County 3. I am/we are the: ( check one )  parent(s)  leg al guardian  next of kin ( specify ): of the minor child(ren). NAM202 State ENG Re v 9/15 www.mncourts.gov/forms Page 2 of 2 4. The current name(s) of minor child(ren) and date(s) of birth: 5. The name of the non -applicant parent(s): The non -applicant parent is not kn own and his/her/their name(s) is/are not shown on the birth certificate. 6. The address of the non -applicant parent(s) is/are: No. Street City/Town State Zip County 7. Applicant requests to have the name(s) of t he minor child(ren) changed to: 8. The criminal history of the following parties included in this application is: ___________________________________________________________________________________ __ _____________________________ ____________________________________________________ The following parties included in this application have been convicted of a felony: _ _ List name, date of offense , and state. If no criminal histor y, write “No criminal history.” If no felony convictions, write “No felony convictions.” 9. Legal description of lands in the State of Minnesota upon which the minor child(ren) has/have a claim, interest, or lien: (Provide the legal description and attach additional pages if necessary) 10. Other: I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116. Dated: Co-Applicant’s Signature (Spouse) Applicant’s Signature Minor Signature (14 years or older) Address Minor Signature (14 years or older) City State Zip ( ) Telephone Number E-mail address