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Fill and Sign the Minnesota Name Change 497312774 Form

Fill and Sign the Minnesota Name Change 497312774 Form

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State of Minnesota District Court County Judicial District: Court File Number: Case Type: Name Change In the Matter of the Application of: First Middle Last Inmate Affidavit for For a change of name to: Name Change (Minn. Stat. § 259.12) First Middle Last STATE OF MINNESOTA ) ) SS COUNTY OF ) I, , the applicant in this matter, make the following statement:  I am currently an inmate confined in a correctional facility, as defined in section 241.021, subdivision 1(f).  I have not at any time during my confinement requested a name change under section 259.10, other than this request.  The reason I am seeking a name change is:  I request the court to issue its Order Granting Name Change. 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: Address: City/State/Zip: NAM105 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 2 Telephone: ( ) E-mail address: NAM105 State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 2

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