packet - name change for minor through age 21 pdf

11/2018

Filing Fee $175.00

Certified Letter Fee $12.00

Fee to Publish in County Paper $_____

Change of Name Minors through 21 Years Old

SH-P.737 (Rev. 8/2019) “Self Help” cannot offer any legal advice

CHANGE OF NAME INSTRUCTIONS MINORS THROUGH 21 YEARS OLD

Self Help Legal Resource Center 811 Port Street, St. Joseph, MI 49085 269.983.7111

1205 N. Front Street, Niles, MI 49120 269.684.5274 Ext. 6202

INSTRUCTIONS FOR FILING A NAME CHANGE These basic instructions will help you complete and file a Petition for Name Change. The Probate Court can help you with your procedural questions, but we cannot give legal advice. If you have legal questions or complex issues, we suggest that you consult with an attorney.

MINORS THROUGH 21 YEARS OLD There is a $175 filing fee for this process. There is an additional $12 fee for certified letters. You must have been a Berrien County resident for at least one year prior to filing. Forms must be typed or printed legibly in black ink (please do not write in cursive). You must attach the birth certificate of the minor to the petition. The interested parties are the legal parents. You will be required to publish in a bonified county paper. There will be a fee.

THINGS YOU SHOULD KNOW BEFORE YOU BEGIN You do NOT need to file a petition for name change if:

A. You would like to use a different combination of your current name such as, “J. Michael Smith” to“Michael J Smith”, or “John M. Smith”, etc. (unless you are intending to use the change on legaldocuments).

B. To correct a MISTAKE on the original birth certificate (check with the Department of PublicHealth, Office of the State Register for the proper procedure.)

CHANGING NAME IN CONJUNCTION WITH AN ADOPTION When an adoption is finalized, the court will include in the Order of Adoption, a section about the new name after adoption. When a certified copy of that order is presented to the Public Health Department with the proper fee, a new birth certificate is prepared with the new information.

CHANGING LAST NAME AFTER PETITION IS ESTABLISHED If the father’s name is not indicated on the birth certificate and, therefore, the child has the mother’s last name, that last name can be changed to the father’s last name after paternity is established. Both parents must agree. Check the Department of Public Health, Office of the State Registrar to use this procedure and confirm the fee.

PETITION FOR NAME CHANGE BY CUSTODIAL PARENT(S) To change the name of a child who is less than 14 years old, both legal parents must agree to the proposed name change, or the custodial parent must prove to the Court that the non-custodial parent

Change of Name Instructions Minors Through 21 Years Old Page 2 of 3

SH- P.737 (Rev. 8/2019 “Self Help” cannot offer any legal advice

has not provided regular or substantial support for the child, or has not substantially compiled with the Court order for support, for 2 years before the filing of the petition, AND the non-custodial parent has substantially failed to contact or visit the child for 2 years before the filing of the petition. The non-consenting non-custodial parent must be given notice of the hearing and an opportunity to object to the proposed name change. The legal parents’ rights are not terminated by a name change. A copy of a divorce decree, custody orders, support orders and statements of arrearage must be attached to the petition if the name change is sought for a minor and the custodial parent is the sole petitioner.

COMPLETING THE PETITION Ensure that all blanks are filled in on both sides of the Petition to Change Name and that all

information is complete and accurate. Sign and date where required. Make as many copies as will benecessary for your records and to serve the interested parties. Attach to the original petition all itemsthat are required from the instructions on the previous page and bring the documents to the ProbateCourt with the correct filing fee.

If you are the legal custodial parent, and the non-custodial parent is consenting to the name change,have him/her fill out and sign #10 on the back page of the petition OR have him/her complete theWaiver/Consent form in the back of this packet. If the legal non-custodial parent is not consenting tothe child’s name to be changed, (s)he must be must be served a copy of the Petition to ChangeName and Notice of Hearing at least 14 days prior to the hearing date. The petitioner mustprovide the Court with a completed Proof of Service form that states that the non-custodialparent was served these documents. If the whereabouts of the non-custodial parent areunknown you must make serious effort to attempt to locate him/her including, but not limitedto, contacting friends, relatives, co-workers, checking whitepages.com, and then complete anAffidavit of attempts to locate Minor’s Parent including having it notarized. If the minor is age14 or over, please ensure items #11 or #12 is completed and the minor is present for the hearing.a. After the petition has been accepted for filing you will be contacted by the Probate Court to set a

hearing date. After receiving the hearing date you must complete “Publication of Notice ofHearing” specifically addressing the non-custodial parent if he/she has not consented (form PC563) and take it to a newspaper that publishes in Berrien County. You cannot publish in theTrade Lines or Mailmax, or any trade lines paper. You must get the form to the newspaper intime for the information to be published 14 days or more before your court date. Thenewspaper will charge you a fee to publish. You will only need to publish one time. A copy of the“Affidavit of Publication” must be filed with the Court prior to your scheduled hearing date.

Following the hearing, if the requirements of the statue are met, the Order for Name Change will be signed by the Judge and the Probate Court will forward a copy to the petitioner or the Petitioner’s attorney along with an “Application to Change a Michigan Birth Certificate” form, (if item #9 requesting the issuance of a new live birth certificate is completed on the order.) If you/the minor were not born in the State of Michigan you must contact the state in which you were born to obtain a copy of the application for a new live birth certificate and the address to which it must be mailed. There is a fee involved. The petition is required to attend the court hearing to provide testimony. If the minor is 14 years old, or older, they are required to attend the hearing.

List of required documents needed to file 1. Petition to Change Name

Change of Name Instructions Minors Through 21 Years Old Page 3 of 3

SH- P.737 (Rev. 8/2019 “Self Help” cannot offer any legal advice

2. Minor’s Birth Certificate (required only when changing a minor’s name)3. Publication of Notice of Hearing4. Notice of Hearing (required only when changing a minor’s name)5. Order following Hearing on Petition to Change Name6. Proof of Service (required only when changing a minor’s name)7. Original Affidavit of Publication (from the newspaper)8. If legal non-custodial parent does not consent to the name change you will also need:

a. Copy of divorce decree or order of filiationb. Custody and support ordersc. Statement of arrearage from Friend of the Court

STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISION

BERRIEN COUNTYPETITION TO CHANGE NAME

CASE NO. and JUDGE

Court address Court telephone no.

Note: Every person 22 years of age or older who is requesting a name change must have a criminal background check. For details, go to michiganlegalhelp.org.

In the matter of Present first, middle, and last name(s) (type or print)

Petitioner’s name, address, and telephone no. Petitioner’s attorney, bar no., address, and telephone no.

PCS Code: NAMTCS Code: PNC

Approved, SCAOForm PC 51, Rev. 1/21MCL 333.2872, MCL 711.1, MCR 3.613Page 1 of 3

For help filling out this form, go to michiganlegalhelp.org

1. An action within the jurisdiction of the family division of circuit court involving the family or family members of

person(s) named above has/have been previously filed in Court,

Case Number

, was assigned to Judge ,and remains is no longer pending.

2. The name change is fora. a married person who wishes to also include a name change for his/her

spouse. minor child(ren), of whom the petitioner has legal custody. (For a minor 14 years or older, written consent is required. See form PC 51b.)

b. an adult.c. a minor, whose natural or adopted parents are

Parent Deceased

and Parent Deceased

.

Both parents are deceased. The guardian is Name

. (Attach letters of guardianship.)

3. The name change is for the following reason:

4. The name change is not sought for any fraudulent intent.

5. The following person(s) seeking a name change has/have a criminal record:

6. Each person for whom a name change is sought has been a resident of the county for at least one year.

811 Port St., St. Joseph, MI 49085 (269) 983-7111

Petition to Change Name (1/21) Page 2 of 3

Case No.

Note: Skip item 7 if the noncustodial parent consents to the name change or if there is not a noncustodial parent.7. I have legal custody of the minor.

a. The noncustodial parent has had the ability to visit, contact, or communicate with the child and has regularly andsubstantially failed or neglected to do so for a period of two years or more before the filing of this petition andeither:

a support order has been entered, and the noncustodial parent has failed to substantially comply with the order for a period of two years or more before the filing of this petition; or

a support order has not been entered and the noncustodial parent, having the ability to support or assist in supporting the child, has failed or neglected to provide regular and substantial support for two years or more before the filing of this petition.

b. The noncustodial parent has been convicted of child abuse (MCL 750.136b), criminal sexual conduct (MCL 750.520b,750.520c, 750.520d, or 750.520e), or assault with intent to commit criminal sexual conduct (MCL 750.520g) and the childor a sibling of the child was the victim. (Attach judgment of sentence.)

c. The noncustodial parent has been convicted of first degree murder (MCL 750.316) or second degree murder(MCL 750.317). (Attach judgment of sentence.)

d. The last known address of the noncustodial parent is:

. The noncustodial parent is not living at the above address, and I have taken the following steps to locate him/her:

8. I request the following name change(s): (Type or print first name, middle name, and last name.)

FROM TO DATE OF BIRTHPetitioner

Put DOB in Ref. No. row 10 on MC 97a.

SpousePut DOB in Ref. No. row 11 on MC 97a.

Minor childPut DOB in Ref. No. row 12 on MC 97a.





If you want a new live birth certificate, check item 9. A special order is not needed if you only want to add the changed name(s) to the original certificate(s).

9. I request the court to order the State Registrar to create a new live birth certificate that does not disclose the name of

Name at birth and to seal the original certificate.

I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief.

Date Petitioner signature

Petition to Change Name (1/21) Page 3 of 3

Case No.

Date Date

Signature Signature

Name (type or print) Name (type or print)

Address Address

City, state, zip Telephone no. City, state, zip Telephone no.

If the petition is filed for a spouse, this consent must be signed by the spouse of the petitioner.

I am the spouse of the petitioner and consent to the granting of this petition to change my name.

Date

Signature Address

Name (type or print) City, state, zip Telephone no.

Attorney signature Address

Attorney name (type or print) Bar no. City, state, zip Telephone no.

SIGNATURE OF PARENT/GUARDIAN FOR MINOR

CONSENT BY SPOUSE OF PETITIONER

Approved, SCAOForm MC 97a, Rev. 9/20MCR 1.109Page 1 of 1

STATE OF MICHIGANJUDICIAL DISTRICT

JUDICIAL CIRCUIT BERRIEN COUNTY

ADDENDUM TOPROTECTED PERSONAL

IDENTIFYING INFORMATION

CASE NO. and JUDGE


JIS Code: API

Plaintiff’s/Petitioner’s namev

Defendant’s/Respondent’s name

In the matter of

This form is nonpublic because it contains personal identifying information (PII) that is protected from public inspection under MCR 1.109(D)(9)(a). Use this form to provide PII only for a person who is a NOT a defendant, respondent, or decedent. If the person is a defendant, respondent, or decedent use form MC 97.Instructions:

• When PII (such as date of birth) must be filed with the court on a public document, DO NOT include it on that publicdocument. Instead, you must provide it on this form.

• Provide only the protected PII required for your particular case. For example, if you are filing a public document thatrequires you to provide a date of birth to the court, complete only that field on this form.

Name of form/document that this MC 97a is being filed with:

Printed name of individual completing form and date

Ref. No.

Instructions: Provide the name of the person that the PII applies to, followed by the specific PII that is required. For Other, specify the type of PII in addition to the PII itself ‑ for example, Social Security No. XXXX. Use the below reference number (Ref. No.) in the public document in place of the protected PII. For example, insert “Ref. No. XX” in place of the DOB in the public document.

10Name DOB Other

11Name DOB Other

12Name DOB Other

13Name DOB Other

14Name DOB Other

15Name DOB Other

16Name DOB Other

17Name DOB Other

18Name DOB Other


SPECIAL INSTRUCTIONS FOR NAME CHANGE

Every person 22 years of age or older whose name appears on the "Petition to Change Name" must follow these instructions before the court can act on the petition.

Pursuant to Michigan law, every person 22 years of age or older who is requesting a name change must have a complete set of fingerprints taken at a local police agency. Those fingerprints will be used by the Michigan State Police and Federal Bureau of Investigation to check criminal records. The Michigan State Police will send a report to the court regarding any criminal records.

If you have a criminal record, it will be presumed that you are seeking the name change with fraudulent intent. You must prove to the court that the name change is not being sought with fraudulent intent.

INSTRUCTIONS:

1. File the "Petition to Change Name" (form PC 51) with the circuit court and pay the filing fee.

2. Make one copy of the completed "Petition to Change Name" (form PC 51 ).

3. Go to your local police agency for the fingerprint card and to have your fingerprints taken. The police agency willadvise you of the appropriate fee. Take a copy of the "Petition to Change Name" with you.

4. After you have had your fingerprints taken, mail the copy of the "Petition to Change Name," the fingerprint card,and the appropriate fee to the Michigan State Police. The fee must be made payable to the State of Michigan. Mailto:

Michigan State Police Criminal Justice Information Center - Criminal History P.O. Box 30266 Lansing, Michigan 48909

5. The Michigan State Police will review your criminal records and will forward the fingerprints to the Federal Bureauof Investigation. Once the Federal Bureau of Investigation has reviewed its records and reported the information tothe Michigan State Police, the Michigan State Police will send a report to the court.

6. After the court receives the required report from the Michigan State Police, the court can schedule a hearing on the"Petition to Change Name."

D The court will mail you a notice when the required report is received. You must give the court a preaddressed,postage-paid envelope for mailing this notice.

D Contact the court eight weeks after you mail or deliver your fingerprint card to the Michigan State Police to find out if the required report has been received.

rev. 09/16

PC 51b (10/15) MINOR’S CONSENT TO CHANGE NAME MCL 333.2872, MCL 711.1(6), MCR 3.613(B)

STATE OF MICHIGAN JUDICIAL CIRCUIT-FAMILY DIVISION

COUNTY MINOR’S CONSENT TO CHANGE NAME

FILE NO.Approved, SCAO

In the matter of the name change of Present first name, middle name, and last name (type or print)

.

JIS CODE: MCC

1. I consent to change my name as stated in the petition filed on Date

.

Date

Minor’s signature

In my presence, the minor who is the subject of this petition signed this consent before me.

Date

Judge Bar no.

NOTE: A minor 14 years of age or older must sign a written consent in the presence of the judge before an order to change name can be entered for that minor. The written consent may be signed at the hearing on the petition to change name.


BERRIEN COUNTY PUBLICATION OF NOTICE OF

HEARING FOR NAME CHANGE

CASE NO. and JUDGE


Approved, SCAOForm PC 50, Rev. 12/19MCL 711.1, MCR 2.106(D), MCR 3.613Page 1 of 1

In the matter of First and last name of child(ren)

TO ALL PERSONS, including: (specify non-custodial parent’s name here, if applicable)

whose address is unknown and whose interest in the matter may be barred or affected by the following:

TAKE NOTICE: A hearing will be held on Date and time

at Location

before Judge to change the name of:

Current nameto

Proposed name

Current nameto

Proposed name

Current nameto

Proposed name

Current nameto

Proposed name

Current nameto

Proposed name

Current nameto

Proposed name

PUBLISH ABOVE INFORMATION ONLY

Publish time(s) in Name of publication

in County.

Furnish copies to .

Furnish affidavit of publication to the court. Petitioner shall file affidavit of publication with the court clerk.

Forward statement for publication charges to .


SH 152 (Rev. 7/18) “Self Help” cannot offer any legal advice

AREA NEWS MEDIA – NEWSPAPER Self Help Legal Resource Center

811 Port Street, St. Joseph, MI 49085 269.983.7111 Ext. 8793 1205 N. Front Street, Niles, MI 49120 269.684.5274 Ext. 6202

Berrien County Record ...................................................................................................... 269.695.3878 324 E. Dewey St., Buchanan, MI 49107 Fax .................................................................................................269.695.3880 Website ...........................................................................................www.bernews@bernews.net

Harbor Country News ........................................................................................................ 269.469.1410 122 N. Whittaker St., New Buffalo, MI 49117 Fax .................................................................................................269.469.3029 Email ...............................................................................................www.harborcountynews@yahoo.com .......................................................................................................or [email protected]

Herald Palladium ................................................................................................................ 269.429.2400 3450 Hollywood Rd., St. Joseph, MI 49085 Toll Free in Michigan only ...............................................................1.800.356.4252 News Desk Fax ...............................................................................269.429.4398 Website ...........................................................................................www.HeraldPalladium.com

Journal Era ......................................................................................................................... 269.473.5421 P.O. Box 98, Berrien Sprints, MI 49103 Fax .................................................................................................269.471.1362 Email ...............................................................................................thejournalera@yahoo.com

New Buffalo Times ............................................................................................................. 269.469.1100 140 N. Whittaker, New Buffalo, MI 49117 Fax .................................................................................................269.469.6397 Email ...............................................................................................newbuffalotimes@i2k.net

South Bend Tribune Niles Bureau, 2232 S. 11th St. ........................................................................................ 269.683.2269 Fax ............................................................................................269.684.6115 Wedbsite ...................................................................................www.southbendtribune.com South Bend Bureau, 225 W Colfax Ave. ......................................................................... 574.235.6161 Email .........................................................................................webmaster@sbtrinfo.com

Tri-City Record ................................................................................................................... 269.463.6397 138 N. Main St., Watervliet, MI 49098 Fax .................................................................................................269.463.8329 Website ...........................................................................................www.tricityrecord.com

http://[email protected]

http://[email protected]

mailto:[email protected]

http://www.heraldpalladium.com/



http://www.southbendtribune.com/


http://www.tricityrecord.com/

In the matter of

1. Titles of the papers served or mailed:

PC 564 (9/10) PROOF OF SERVICE

JIS CODE: PSVApproved, SCAO

FILE NO.PROOF OF SERVICE

MCL 700.1306, MCL 700.1401, MCR 5.104(A), MCR 5.105, MCR 5.107

Do not write below this line - For court use only

Name

2. According to court rule, I served by first-class mail registered mail (copy of return receipt attached)certified mail (copy of return receipt attached) the papers described above on:

3. According to court rule, I served by personal service the papers described above on:

4. After diligent search and inquiry, I have been unable to find and serve the following interested persons. I have served thesepersons by publication. Attached are copies of form PC 617.

I declare under the penalties of perjury that this proof of service has been examined by me and that its contents are true to the bestof my information, knowledge, and belief.

DateComplete address of service

Name Complete address of service Date and Time

Date

Signature

STATE OF MICHIGAN PROBATE COURT COUNTY OF BERRIEN

$ $Service fee Miles traveled Fee

Incorrect address fee Miles traveled Fee TOTAL FEE$ $ $

USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.

Name (type or print)

1. I am interested in the matter as .

2. I waive notice of the hearing and consent to the application/petition for

, and I declare that I have received a copy of this application/petition.

3. I waive notice of the hearing concerning .

PC 561 (9/07) WAIVER/CONSENT

In the matter of


JIS CODE: WACApproved, SCAO

FILE NO.WAIVER/CONSENT

MCL 700.1402, MCR 5.104(B)

Nature of hearing

Date

Signature

Name (type or print)

Address

City, state, zipTelephone no.

Bar no.Attorney name (type or print)

Address

City, state, zip Telephone no.

Nature of application/petition and name of applicant/petitioner

STATE OF MICHIGANPROBATE COURT BERRIEN COUNTY

CIRCUIT COURT - FAMILY DIVISION

NOTE: Do not use for waivers pursuant to MCL 700.3310.


PC 562 (12/17) NOTICE OF HEARING MCL 700.1401, MCL 710.21 et seq., MCR 3.802(A)(3), MCR 5.102, MCR 5.109(2)

Approved, SCAO JIS CODE: NOH

STATE OF MICHIGAN PROBATE COURT COUNTY OF BERRIEN NOTICE OF HEARING

FILE NO.

In the matter of First, middle, and last name

TAKE NOTICE: A hearing will be held on Date

at Time

,

at Location

before Judge Bar no.

for the following purpose(s): (state the nature of the hearing)

If you require special accommodations to use the court because of a disability, or if you require a foreign language interpreter to help you fully participate in court proceedings, please contact the court immediately to make arrangements.

Date

Attorney name Bar no. Petitioner name

Address Address

City, state, zip Telephone no. City, state, zip Telephone no.

USE NOTE TO COURT: If this hearing is for a guardianship matter involving an Indian child as defined in MCR 3.002(12), you must comply with MCR 5.109(2).

USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.


BERRIEN COUNTY

ORDER FOLLOWING HEARING ONPETITION TO CHANGE NAME

(Part 1)

CASE NO. and JUDGE



JIS Code: OCN


Distribute form to:Court, Part 2Petitioner, Part 1Law enforcement, Part 1 (as needed)Department of Corrections, Part 1 (as needed)

THE COURT FINDS:

1. A petition for name change has been filed.

2. Notice of hearing was given by publication.


4. The court has received the required criminal record report(s) from the Michigan Department of State Police.

5. Name (type or print)

has a criminal record.

6. The request for the name change of Name (type or print)

is is not made with fraudulent intent.

7. The petitioner, having legal custody, requests the name change of a minor. The noncustodial parent has consented tothe name change.

8. The petitioner requests the name change of a minor. The custodial parent has consented to the name change. Thenoncustodial parent was given notice of the hearing.

a. The noncustodial parent has had the ability to visit, contact, or communicate with the minor but has regularly andsubstantially failed or neglected to do so for the past two years, and

a support order has been entered, and the noncustodial parent has failed to substantially comply with the order for a period of two years or more before the filing of the petition for name change. or

a support order has not been entered and the noncustodial parent, having the ability to support or assist supporting the child, has failed or neglected to provide regular and substantial support for two years or more before the filing of the petition for name change.

b. The noncustodial parent has been convicted of child abuse (MCL 750.136b), criminal sexual conduct (MCL 750.520b,750.520c, 750.520d, or 750.520e), or assault with intent to commit criminal sexual conduct (MCL 750.520g), and the childor a sibling of the child was the victim.

9. The minor(s) 14 years of age or older signed a written consent to change name in the presence of the court.

10. The minor(s) under the age of 14 has/have stated a preference to a name change.

11. The minor(s) is/are not of sufficient age to express a preference to a name change.


Order Following Hearing on Petition to Change Name (1/21) Page 2 of 2

Case No.

12. The name(s) of the following person(s) is/are changed.

FROM TO DATE OF BIRTHPetitioner month, day, year

Spouse month, day, year

Minor child month, day, year




13. The State Registrar shall create a new live birth certificate for Name

that does not disclose the name at birth and shall seal the original certificate.

14. The request to change the name of Name

is denied.

15. The request is denied and the petition is dismissed.

Judge signature and date

Attorney Name (type or print) Bar no.

Address


Note to Petitioner: You must provide this order to the State Registrar if you want to change your birth certificate.

Note to Clerk: Under MCL 711.1(3), if the court enters an order to change the name of a person who has a criminal record, the court shall forward the order to the Criminal Justice Information Center of the Michigan State Police and to one or more of the following:

• The Department of Corrections if the person named in the order is in prison or on parole or has been imprisoned orreleased from parole in the immediately preceding two years.

• The sheriff of the county in which the person named in the order was last convicted if the person was incarcerated in acounty jail or released from a county jail within the immediately preceding two years.

• The court that has jurisdiction over the person named in the order if the person named in the order is under the jurisdictionof the family division of the circuit court.


BERRIEN COUNTY

ORDER FOLLOWING HEARING ONPETITION TO CHANGE NAME

(Part 2)

CASE NO. and JUDGE



JIS Code: OCN


Distribute form to:Court, Part 2Petitioner, Part 1Law enforcement, Part 1 (as needed)Department of Corrections, Part 1 (as needed)

THE COURT FINDS:

1. A petition for name change has been filed.

2. Notice of hearing was given by publication.


4. The court has received the required criminal record report(s) from the Michigan Department of State Police.

5. Name (type or print)

has a criminal record.

6. The request for the name change of Name (type or print)

is is not made with fraudulent intent.

7. The petitioner, having legal custody, requests the name change of a minor. The noncustodial parent has consented tothe name change.

8. The petitioner requests the name change of a minor. The custodial parent has consented to the name change. Thenoncustodial parent was given notice of the hearing.

a. The noncustodial parent has had the ability to visit, contact, or communicate with the minor but has regularly andsubstantially failed or neglected to do so for the past two years, and

a support order has been entered, and the noncustodial parent has failed to substantially comply with the order for a period of two years or more before the filing of the petition for name change. or

a support order has not been entered and the noncustodial parent, having the ability to support or assist supporting the child, has failed or neglected to provide regular and substantial support for two years or more before the filing of the petition for name change.

b. The noncustodial parent has been convicted of child abuse (MCL 750.136b), criminal sexual conduct (MCL 750.520b,750.520c, 750.520d, or 750.520e), or assault with intent to commit criminal sexual conduct (MCL 750.520g), and the childor a sibling of the child was the victim.

9. The minor(s) 14 years of age or older signed a written consent to change name in the presence of the court.

10. The minor(s) under the age of 14 has/have stated a preference to a name change.

11. The minor(s) is/are not of sufficient age to express a preference to a name change.


Order Following Hearing on Petition to Change Name (1/21) Page 2 of 2

Case No.

12. The name(s) of the following person(s) is/are changed.

FROM TO DATE OF BIRTHPetitioner month, day, year

Spouse month, day, year





13. The State Registrar shall create a new live birth certificate for Name

that does not disclose the name at birth and shall seal the original certificate.

14. The request to change the name of Name

is denied.

15. The request is denied and the petition is dismissed.

Judge signature and date

Attorney Name (type or print) Bar no.

Address


Note to Petitioner: You must provide this order to the State Registrar if you want to change your birth certificate.

Note to Clerk: Under MCL 711.1(3), if the court enters an order to change the name of a person who has a criminal record, the court shall forward the order to the Criminal Justice Information Center of the Michigan State Police and to one or more of the following:

• The Department of Corrections if the person named in the order is in prison or on parole or has been imprisoned orreleased from parole in the immediately preceding two years.

• The sheriff of the county in which the person named in the order was last convicted if the person was incarcerated in acounty jail or released from a county jail within the immediately preceding two years.

• The court that has jurisdiction over the person named in the order if the person named in the order is under the jurisdictionof the family division of the circuit court.

packet - name change for minor through age 21 pdf

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