Free State of Minnesota - Minnesota

State of Minnesota
County

District Court
Judicial District: Court File Number: Case Type: Name Change

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In the Matter of the Application of:
First Middle Last

For a change of name to:

Order Granting Name Change (Minn. Stat. § 259.10)
Last

First

Middle

The above entitled matter came on for hearing before the undersigned Judge on _________________________ upon the
Date

Application for a Name Change. Upon the testimony and files, THE COURT FINDS the following: 1. 2. The application is made in good faith without intent to defraud or mislead. 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: No. in 3. 4. Name of applicant and date of birth: Name of spouse and date of birth: This application does does not include spouse. 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: Street County. City/Town State Zip

5.

6.

This applicant requests: To have his/her name changed to To have the name of his/her spouse changed to To have the name(s) of his/her child (ren) changed to 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 AND Proper notice has been given to the prosecuting authority and Minnesota Attorney General No objection has been filed.

7.

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)

NAM107

State

ENG

Rev 8/05

www.mncourts.gov/forms

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9.
The

Other: . application is granted and IT IS ORDERED that:

The legal name of the Applicant shall be The legal name of the spouse shall be The legal names of the minor child (ren) shall be All persons having a criminal history who have been granted a name change by 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.

NAM107

State

ENG

Rev 8/05

www.mncourts.gov/forms

Page 2 of 2