Name (currently used) 

 
Address 

 
City, State, Zip 

 
Phone 

 
Email 

 

 

 
 
 
 
 
 
 
Check your email. You will receive information and 
documents at this email address.  

In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

In the Matter of the Name Change of: 

Department of Corrections 
Certification Regarding Sex and 
Kidnap Offender and Child Abuse 
Offender Registries – Adult  

_____________________________________ 
Petitioner (current legal name) 
 

_______________________________ 
Case Number 

_______________________________ 
Judge 

 

 

Petitioner’s full name 
(first, middle and last) 
 

Date of Birth 
(MM/DD/YYYY) 

Driver license / state ID 
number and state of 
issuance 

 

 

 

1701FAJ Approved March 11, 
2022 
 

Department of Corrections Certification Regarding Sex and Kidnap 
Offender Registry and Child Abuse Offender Registry – Adult 

Page 1 of 2 

 

 -------------- This section to be completed by Offender Registration Program staff -------------- 

I certify that I searched Utah’s Sex and Kidnap Offender Registry and Child Abuse 
Offender Registry for 

 _____________________________________________________________ (name) 
and the search results were: 

Child Abuse Offender Registry 

[  ]  Positive – the above-named person is on the Child Abuse Offender Registry. 

[  ]  Negative – the above-named person is not on the Child Abuse Offender Registry. 

[  ]  Other: ___________________________________________________________ 

Sex and Kidnap Offender Registry 

[  ]  Positive – the above-named person is on the Sex and Kidnap Offender Registry. 

[  ]  Negative – the above-named person is not on the Sex and Kidnap Offender 

Registry. 

[  ]  Other: ___________________________________________________________ 

Signature ► 

 

Printed Name of Offender 
Registration Program staff 

 

 

           

 

Date 

1701FAJ Approved March 11, 
2022 
 

Department of Corrections Certification Regarding Sex and Kidnap 
Offender Registry and Child Abuse Offender Registry – Adult 

Page 2 of 2 

 

Instructions 

Complete the form. Leave the section that says “This section to be completed by  
Offender Registration Program staff” blank. 

Address an envelope to yourself with your name and mailing address and put a 
stamp on it so that the completed form can be mailed back to you. 

3. 

Mail the form and your self-addressed stamped envelope to: 

 
 
 

Offender Registration Program 
14717 Minuteman Drive 
Draper, UT 84020 

You must mail this form to the Offender Registration Program. They do not have 
an office open to the public. 

The Offender Registration Program staff will fill out their section and will return 
the completed form to you using the envelope you provided.  

Once the form is mailed back to you, file it with the court along with the rest of 
your paperwork. 

1. 

2. 

4. 

5. 

6. 

1701FAF Approved July 13, 2020 

Department of Corrections Certification Regarding Sex and Kidnap  
Offender Registry and Child Abuse Offender Registry – Adult