Fill and Sign the Michigan Change Name Document Form

Approved, SCAO OSM CODE: NAM STATE OF MICHIGAN       JUDICIAL CIRCUIT – FAMLY DIVISION       COUNTY PETITION TO CHANGE NAME FILE NO. In the matter of the name change of       Present first name(s), middle name(s), and last name(s) (type or print) to       Requested new first name(s), middle name(s), and last name(s) (type or print) 1. An action within the jurisdiction of the family division of the circuit court involving the family or family members of the above named person(s) has been previously filed in       Court, Case Number       , was assigned to Judge       , and remains is no longer pending. 2. The name change is for: a. a married person who wishes to also include a name change for: his/her spouse. his/her minor child(ren), of whom the petitioner has legal custody. b. an adult. c. a minor, whose natural or adopted parents are:       and Mother       . Father Both parents are deceased. The guardian is       . (attach letters of guardianship) Name 3. The name change is for the following reason:       4. The name change is not sought for any fraudulent intent. 5. The following person(s) seeking a name change have a criminal record:             6. Each person for whom a name change is sought has been a resident of the county for at least one year. [Complete item 7. only if the name change is for a minor. Please see other side for remainder of petition.] 7. I have legal custody of the minor. a. The noncustodial parent has had the ability to visit, contact, or communicate with the child and has regularly and substantially failed or neglected to do so for a period of two years or more before the filing of this petition and either: a support order has been entered, and the noncustodial parent has failed to substantially comply with the order for a period of two years or more before the filing of this petition; or a support order has not been entered and the noncustodial parent, having the ability to support or assist in supporting the child, has failed or neglected to provide regular and substantial support for two years or more before the filing of this petition. b. The noncustodial parent has been convicted of child abuse (MCL750.136b) , criminal sexual conduct (MCL750.520b, MCL750.520c, 750.520d, or 750.520e) , or assault with intent to commit criminal sexual conduct (MCL 750.52og) and the child or a sibling of the child was the victim. (attach judgment of sentence) c. The last known address of the noncustodial parent is:             The noncustodial parent is not living at the above address, and I have taken the following steps to locate him/her:       (SEE SECOND PAGE) Do not write below this line - For court use only PC 51 (9/10) PETITION TO CHANGE NAME MCL 333.2872, MCL 711.1, MCR 3.613 8. I request the following name change(s): (type or print first name, middle name, and last name) FROM TO DATE OF BIRTH Petitioner             month, day, year       Spouse             month, day, year       Minor child             month, day, year       Minor child             month, day, year       Minor child             month, day, year       Minor child             month, day, year       If you want a new live birth certificate, check item 9. A special order is not needed if you only want to add the changed name(s) to the original certificate(s). 9. I request the court to order the State Registrar to create a new live birth certificate that does not disclose the name of       at birth and to seal the original certificate. Name I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief.             Date Date Petitioner signature Petitioner signature             Name (type or print) Name (type or print)             Address Address             City, state, zip Telephone no. City, state, zip Telephone no. 10. I am the spouse of the petitioner and consent to the granting of this petition to change my name.       Date Spouse's signature 11. 1 am a minor 14 years of age or older, and I consent to the granting of this petition to change my name.       Date Minor's signature       Date Minor's signature 12. I am a minor under 14 years of age, and I state my preference to the name change above.       Date Minor's signature       Date Minor's signature       Attorney signature Address                         Attorney name (type or print) Bar no. City, state, zip Telephone no.