State
of Minnesota
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District Court
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County
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Court File Number:
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Case Type:
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Name
Change
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In
the Matter of the Application of (current name):
First Middle Last
For
a change of name to (new name): Application for Name Change
(Minn.
Stat. § 259.10)
First Middle Last
The
undersigned applicant sworn/affirmed on oath states that:
1.
This application
is made in good faith, without intent to defraud or mislead.
2. All
persons who are asking to have their names changed on this application have
lived in the State of Minnesota
for at least six months immediately prior to the date of this application, and
now live at:
No. Street
City/Town State Zip County
3. Name of applicant and date of birth:
4. Name of applicant’s spouse and date of birth:
This
application o does o does not
include spouse.
5.
Name(s) of minor child(ren) and date(s) of birth:
o This
application does not include minor child(ren) listed above.
o This
application includes the following minor child(ren) listed above:
6. The name and address of the non-applicant
parent is:
7.
Applicant requests:
o To have
his/her name changed to
o To have the
name of his/her spouse changed to
o To have the
names of his/her minor child(ren) changed to
8.
The criminal
history of the following parties included in this application is: ____________________________________
_________________________________________________________________________________________________
The following parties included in this application
have been convicted of a felony:
List name, date of offense, and
state. If no criminal history, write “No criminal history.” If no felony convictions, write “No
felony convictions.”
9.
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)
o Applicant
o Spouse
o
Child(ren)
10.
o I am currently involved in a victim or witness
protection program.
11.
o I am an inmate in a correctional facility, and have
attached the Inmate Affidavit for Name Change.
12.
Other:
.
Date:
