Application For Change Of Name Of Adult {21.0}

PROBATE COURT OF STARK COUNTY, OHIO IN RE: CHANGE OF NAME OF TO CASE NO. DIXIE PARK , JUDGE (Present Name) (Name Requested) APPLICATION FOR CHANGE OF NAME OF ADULT [R.C. 2717.01] The applicant states that the applicant is an adult and has been a bona fide resident of Stark County, Ohio for at least one year immediately prior to the filing of this application. The applicant requests a change of name from to for the following reason: The applicant states that the applicant will cause notice of the application to be published once in a newspaper of general circulation in this county at least thirty (30) days before the hearing on this application. The applicant states that the applicant 1 ) ___ 2) ___ initials initials has has not been convicted of, pleaded guilty to, or been adjudicated a delinquent child for identity fraud. has a has no duty to comply with ORC 2950.04 or ORC 2950.041 because the applicant was convicted of, pled guilty to, or was adjudicated a delinquent child for having committed a sexually oriented offense or a child-victim oriented offense. Applicant's Signature Typed or Printed Name Attorney for Applicant Typed or Printed Name Address Address City State Zip City State Zip Telephone Number (include area code) Attorney Registration No. Telephone Number (include area code) FORM 21.0 - APPLICATION FOR CHANGE OF NAME OF ADULT 1/1/2013 American LegalNet, Inc. www.FormsWorkFlow.com [REVERSE OF FORM 21.0] Case No. JUDGMENT ENTRY SETTING HEARING AND ORDERING NOTICE The Court orders this application set for hearing on the at o'clock .M. day of I The applicant is ordered to cause notice of the application to be given by one publication in a newspaper of general circulation in this county at least thirty (30) days prior to the hearing date as required by law. DIXIE PARK - Probate Judge By : Deputy Clerk FORM 21.0 - APPLICATION FOR CHANGE OF NAME OF ADULT (PAGE 2) 1/1/2013 American LegalNet, Inc. www.FormsWorkFlow.com