Free State of Minnesota - Minnesota

State of Minnesota
County

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

Select County

Name Change

In the Matter of the Application of: First Middle Last

For a change of name to: First Middle Last

Felon Name Change Notice Pursuant to Minn. Stat. § 259.13

TO:

(Check all that apply)
Print County and State of your conviction or print federal district if convicted under federal law.

Prosecuting Authority for Minnesota Attorney General (Minnesota Attorney General must also be served if conviction is federal or out of state). 1. This notice is to inform you that the Applicant has applied for a change of name in the District Court by filing a: (check one) Application for Name Change Application for a Marriage License with Name Change Application for Name Change Pursuant to a Marriage Dissolution 2. A copy of the Application showing the present full legal name and the requested name is attached. Any correspondence concerning this Application should be addressed to Court Administrator at the following address: . 3. This Notice is served to comply with Minn. Stat. § 259.13. Any objection must be filed within 30 days of service of this notice. County

Dated:
Signature

Name: Street Address: City/State/Zip:

NAM104

State

ENG

Rev 4/01

www.courts.state.mn.us/forms

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