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IN THE WARREN COUNTY, OHIO COMMON PLEAS COURT PROBATE DIVISION IN RE: CHANGE OF NAME OF _______________________________________________________ (Present Name) To _______________________________________________________________________________ (Name Requested) CASE NO. _______________________ 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 ______________________ 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 1) _______ has has not been convicted of, pleaded guilty to, or been adjudicated a delinquent child for Initials identity fraud 2) _______ has a has no duty to comply with R.C. 2950.04 or R.C. 2950.041 because the applicant was Initials convicted of, pled guilty to, or was adjudicated a delinquent child for having committed a sexually oriented offense or a childvictim oriented offense. ____________________________________ Attorney for Applicant ____________________________________ Typed or Printed Name ____________________________________ Address ____________________________________ City State Zip ____________________________________ Telephone Number (include area code) _____________________________________ Applicant's Signature ____________________________________ Typed or Printed Name ____________________________________ Address ______________________________________ City State Zip _____________________________________ Telephone Number (include area code) Attorney Registration No. ____________________________ FORM 21.0 APPLICATION FOR CHANGE OF NAME OF ADULT Amended: January 1, 2013 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. _________________ JOURNAL ENTRY SETTING HEARING AND ORDERING NOTICE The Court orders this application set for hearing on the ______ day of ___________________, ________, at _________o'clock ____. M. 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 well as certified mail service, return receipt requested, if necessary, as required by law. __________________________________________ Probate Judge By: __________________________________________ Deputy Clerk FORM 21.0 APPLICATION FOR CHANGE OF NAME OF ADULT Page 2 Amended: January 1, 2013 American LegalNet, Inc. www.FormsWorkFlow.com