Fill and Sign the Name Change Minnesota Judicial Branch Form

NAM107 State ENG Rev 08/14 www.mncourts.gov/forms Page 1 of 3 State of Minnesota District Court County Judicial District: Court File Number: Case Type: Name Change In the Matter of: First Middle Last Order Granting Name Change And Other Relief For a change of name to: (Minn. Stat. § 259.10, § 144.218, and § 144.2181) First Middle Last The above entitled matter came on for hearing before the undersigned Judge on _________________________ upon the Application for a Name Change and Other Relief. Upon the Date testimony and files, THE COURT FINDS the following: 1. The application is made in good faith without intent to defraud or mislead. 2. The applicant(s) has/have lived in the State of Minnesota for at least six months preceding the filing of the application, and now live at: Street City/Town State Zip in County. 3. Name of applicant and date of birth: 4. Name of spouse and date of birth: This application  does  does not include spouse. 5. Name(s) of minor children and date(s) of birth:  This application does not include minor children listed above.  This application includes the following minor children listed above: NAM107 State ENG Rev 08/14 www.mncourts.gov/forms Page 2 of 3 6. This applicant requests:  To have his/her name changed to  To have his/her name changed on birth records created or maintained by the Minnesota Department of Health to  To have his/her sex changed on birth records created or maintained by the Minnesota Department of Health to .  To have the Minnesota Department of Health issue and register a replacement birth record. Applicant further requests the prior birth record be kept confidential and the replacement birth record not to include any reference to Applicant’s  former name  former sex.  To have the name of his/her spouse changed to  To have the name(s) of his/her child (ren) changed to 7. The applicant (and included spouse or child (ren))  Has not been convicted of a felony in any state.  Has been convicted of a felony as follows: AND  Proper notice has been given to the prosecuting authority and Minnesota Attorney General AND  No objection has been filed. 8. Legal description of lands in the State of Minnesota upon which the following have a claim, interest, or lien: (Provide the legal description and attach additional pages if necessary.)  Applicant  Spouse  Child (ren) 9. Other: . The application is granted and IT IS ORDERED that:  The legal name of the Applicant shall be  The legal name of the spouse shall be NAM107 State ENG Rev 08/14 www.mncourts.gov/forms Page 3 of 3  The legal names of the minor child (ren) shall be  The Minnesota Department of Health shall change the name on the birth record from to  The Minnesota Department of Health shall change the sex on the birth record from to .  The Minnesota Department of Health shall issue and register a replacement birth record for the Applicant. The prior birth record shall be confidential pursuant to Minn. Stat. § 13.02, subdivision 3, and shall not be disclosed except pursuant to court order.  The replacement birth record shall not include any reference to the Applicant’s  former name  former sex and  shall reflect the Applicant’s current legal name of  shall reflect the sex designation of . . All persons having a criminal history who have been granted a name change b y this court have a duty to report that name change to the Bureau of Criminal Apprehension within ten (10) days of this order.  Other Dated: Judge of District Court DUTY TO REPORT NAME CHANGE Minn. Stat. § 259.11B If you have a criminal history and have changed your name, you have a duty to report your name change to the Bureau of Criminal Apprehension located at 1430 East Maryland Avenue, St Paul, MN 55106, (651)793- 2400, within ten (10) days of this order. Failure to do so is a gross misdemeanor punishable by up to one (1) year in prison and/or a fine of $3000.