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 

_____________________________________ 
(Name of person whose information will be changed) 

[  ]  A minor. 

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

_______________________________ 
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 November 21, 
2022 
 

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

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 November 21, 
2022 
 

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

Page 2 of 2 

 

Instructions 

1. 

2. 
 

 

 

 

 

 

 

 
 

 
 
 

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

Either email or mail the form to the Offender Registration Program 
You have two options to send the form – email or mail. Only do one of them. 

Option A: Email a scanned PDF of the completed form to registry@utah.gov. 

The Program will reply to your email with the completed form. 

Option B: Send the form through the US mail. You cannot drop off the form in 
 

person. 

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. 

Put the envelope you addressed to yourself and the form in another 
envelope. Send that envelope to: 

Offender Registration Program 
14717 Minuteman Drive 
Draper, UT 84020 

3.  Wait 
 

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

4. 

File the form with the court, along with your other paperwork 
Once the form is returned to you, file it with the court along with your petition and 
order. 

If you aren’t sure what to do with this form, visit www.utcourts.gov/selfhelp or contact 
the Self-Help Center at: 

 

 

Email: 
Text:  
Phone:  

selfhelp@utcourts.gov 
801-742-1898 
888-683-0009 

1701FAJ Approved November 21, 
2022 
 

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