Fillable STATE OF MICHIGAN CASE NO. and JUDGE PETITION (Michigan)

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STATE OF MICHIGAN CASE NO. and JUDGE PETITION (Michigan)

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STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
PETITION TO CHANGE NAME
CASE NO. and JUDGE
Court address Court telephone no.
Note: This petition must be accompanied by a notice of hearing prepared for publication under MCR 3.613 (see PC 50). 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: NAM
TCS Code: PNC
Approved, SCAO
Form PC 51, Rev. 4/21
MCL 333.2872, MCL 711.1, MCR 3.613
Page 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 for
a. 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.
Petition to Change Name (4/21)
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 and
substantially failed or neglected to do so for a period of two years or more before the filing of this petition and
either:
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 child
or 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 BIRTH
Petitioner
Put DOB in Ref. No. row 10 on MC 97a.
Spouse
Put DOB in Ref. No. row 11 on MC 97a.
Minor child
Put DOB in Ref. No. row 12 on MC 97a.
Minor child
Put DOB in Ref. No. row 13 on MC 97a.
Minor child
Put DOB in Ref. No. row 14 on MC 97a.
Minor child
Put DOB in Ref. No. row 15 on MC 97a.
Minor child
Put DOB in Ref. No. row 16 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 (4/21)
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
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STATE OF MICHIGAN CASE NO. and JUDGE PETITION (Michigan)

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Completed 24 March 2022

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