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STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
ORDER FOLLOWING HEARING ON
PETITION TO CHANGE NAME
(Part 1)
CASE NO. and JUDGE
Court address
Court telephone no.
3. Each person for whom a name change is sought has been a resident of the county for at least one year.
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 to
the name change.
8. The petitioner requests the name change of a minor. The custodial parent has consented to the name change. The
noncustodial parent was given notice of the hearing.
a support order has been entered, and the noncustodial parent has failed to substantially comply with the
a. The noncustodial parent has had the ability to visit, contact, or communicate with the minor but has regularly and
substantially failed or neglected to do so for the past two years, and
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.
order for a period of two years or more before the filing of the petition for name change. or
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.
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.
In the matter of
Present first, middle, and last name(s) (type or print)
THE COURT FINDS:
1. A petition for name change has been filed.
2. Notice of hearing was given by publication.
JIS Code: OCNApproved, SCAOForm PC 52, Rev. 1/21MCL 333.2872, MCL 711.1, MCR 3.613Page 1 of 2Distribute form to:Court, Part 2Petitioner, Part 1Law enforcement, Part 1 (as needed)Department of Corrections, Part 1 (as needed) Order Following Hearing on Petition to Change Name
Page 2 of 2
(1/21)
Case No.
12. The name(s) of the following person(s) is/are changed.
FROM
TO
Petitioner
Spouse
Minor child
Minor child
Minor child
Minor child
13. The State Registrar shall create a new live birth certificate for
that does not disclose the name at birth and shall seal the original certificate.
Name
14. The request to change the name of
Name
15. The request is denied and the petition is dismissed.
Judge signature and date
Attorney Name (type or print)
Bar no.
Address
City, state, zip
Telephone no.
DATE OF BIRTH
month, day, year
month, day, year
month, day, year
month, day, year
month, day, year
month, day, year
is denied.
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 or
released 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 a
county 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 jurisdiction
of the family division of the circuit court.
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
ORDER FOLLOWING HEARING ON
PETITION TO CHANGE NAME
(Part 2)
CASE NO. and JUDGE
Court address
Court telephone no.
3. Each person for whom a name change is sought has been a resident of the county for at least one year.
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 to
the name change.
8. The petitioner requests the name change of a minor. The custodial parent has consented to the name change. The
noncustodial parent was given notice of the hearing.
a support order has been entered, and the noncustodial parent has failed to substantially comply with the
a. The noncustodial parent has had the ability to visit, contact, or communicate with the minor but has regularly and
substantially failed or neglected to do so for the past two years, and
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.
order for a period of two years or more before the filing of the petition for name change. or
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.
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.
In the matter of
Present first, middle, and last name(s) (type or print)
THE COURT FINDS:
1. A petition for name change has been filed.
2. Notice of hearing was given by publication.
JIS Code: OCNApproved, SCAOForm PC 52, Rev. 1/21MCL 333.2872, MCL 711.1, MCR 3.613Page 1 of 2Distribute form to:Court, Part 2Petitioner, Part 1Law enforcement, Part 1 (as needed)Department of Corrections, Part 1 (as needed) Order Following Hearing on Petition to Change Name
Page 2 of 2
(1/21)
Case No.
12. The name(s) of the following person(s) is/are changed.
FROM
TO
Petitioner
Spouse
Minor child
Minor child
Minor child
Minor child
13. The State Registrar shall create a new live birth certificate for
that does not disclose the name at birth and shall seal the original certificate.
Name
14. The request to change the name of
Name
15. The request is denied and the petition is dismissed.
Judge signature and date
Attorney Name (type or print)
Bar no.
Address
City, state, zip
Telephone no.
DATE OF BIRTH
month, day, year
month, day, year
month, day, year
month, day, year
month, day, year
month, day, year
is denied.
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 or
released 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 a
county 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 jurisdiction
of the family division of the circuit court.
