Fill and Sign the Utah Ad Litem 497427698 Form

_____________________________ (Applicant’s Name) _____________________________ (Address) _____________________________ (City) _____________________________ (Telephone) ____________ DISTRICT COURT, ______________________ COUNTY, UTAH COURT’S ADDRESS: _____________________________________________________ IN THE MATTER OF THE NAME CHANGE OF: ______________________________ , . ORDER APPOINTING GUARDIAN AD LITEM (minor’s name) A minor. Case No. ____________________ Judge _______________________ There is good cause to support the application of ______________________________ (name of applicant) for the appointment of a guardian ad litem to represent the minor in this name change action. It is ordered that ________________________________________ ______ be appointed (name of guardian(s) ad litem as guardian ad litem for _____________________________________________________ in (name of minor) this name change action. Minor’s Name Change: Order Appointing G.A.L.., p. 1 Approved: November 19, 2004 The costs of the guardian ad litem are apportioned as follows: [ ] No costs are anticipated. [ ] Costs for the guardian ad litem will be paid for by ________________________________ (name and percentage of costs to be paid). ________________________________ (name and percentage of costs to be paid). ________________________________ ( name and percentage of costs to be paid). ________________________________ (name and percentage of costs to be paid). Minor’s Name Change: Order Appointing G.A.L.., p. 2 Approved: November 19, 2004 DATED: ___________________ ______________________________________ District Court Judge CERTIFICATE OF DELIVERY On __________________________ (date) , I [ ] hand-delivered, [ ] mailed by first class mail, postage prepaid, a copy of the foregoing ORDER FOR APPOINTMENT OF GUARDIAN AD LITEM to: Name: Address: Name: Address: Name: Address: ____________________________________ Applicant = s Signature Minor’s Name Change: Order Appointing G.A.L.., p. 3 Approved: November 19, 2004