Minnesota Order Granting Name Change Form

The Minnesota Order Granting Name Change Form is a form that you have to complete and submit to the clerk’s office, regardless of having a scheduled hearing or not.

Extracted Text for Proper Search

NAM107     State  ENG     Rev 8/05            www.mncourts.gov/forms	                                         Page 1 of 2 	
 
   Court File Number:   
   Case Type: 
 
In the Matter of the Application of: 
 
      	
 	First  Middle   Last    
                  	Order Granting Name Change	 
For a change of name to:                    	
(Minn. Stat. § 259.10)	 
 
      	
 	First   Middle   Last 
 
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.  The application is made in good faith without intent to defraud or mislead. 
 
2.   The applicant(s) has/have lived in the St ate of Minnesota for at least six months preceding the filing of the application, and   
 
now live at:                	
 
No. Street    City/Town  State  Zip 
in        	
 County. 
 
3.   Name of applicant and date of birth:            	
 
 
4.   Name of spouse and date of birth:            
 
This application    † does  † does not include spouse. 
 
5.   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:             
 
              
 
 
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                 
 
 
7.   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  † Proper notice has been given to the prosecuting authority and Minnesota Attorney General 
AND  † No objection has been filed. 
 
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	                                         Page 2 of 2 	
 	
 
9.   Other:               	
 
               
. 	 
T
he 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                   
 
 
 
 
 
 	
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 ha ve 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.