Reset Name of Person Filing: ____________________________________ Mailing Address: ____________________________________ City, State, Zip Code: ____________________________________ Daytime/Evening Phone Number: ____________________________________ ATLAS Number (if applicable) ____________________________________ Attorney Bar Number (if applicable) ____________________________________ Represented by Self or by Attorney
FOR CLERK USE ONLY
SUPERIOR COURT OF ARIZONA MOHAVE COUNTY
In the Matter of Case Number:
CONSENT OF PARENT TO NAME CHANGE OF A MINOR CHILD AND WAIVER OF NOTICE
a Minor
REQUIRED INFORMATION FROM PARENT, UNDER OATH OR AFFIRMATION: 1. INFORMATION ABOUT ME:
Name: _______________________________________________________________________________ Address: _____________________________________________________________________________ Telephone: _________________________________ Date of Birth: _______________________ Month Place of Birth:_______________________ City I am the natural I am the adoptive MOTHER or MOTHER or ______________________ Date ______________________ State ___________________ Year ___________________ Nation
FATHER of the minor child named above. FATHER of the minor child named above.
2.
I have read the Application for Name Change and consent to changing the child's LEGAL name to: First: ____________________ Middle: ____________________ Last:______________________
3.
I waive notice of all further proceedings in this matter.
OATH OR AFFIRMATION
STATE OF ARIZONA ) COUNTY OF MOHAVE ) ss. The contents of this document are true and correct to the best of my knowledge and belief. Signature: _______________________________________ Date:______________________
Sworn to or affirmed before me on this ______________________ day of ___________________, 20___________ By:___________________________________ My Commission Expires: _________________________ ________________________________________ Notary Public or Deputy Clerk
10/23/2006