On July 15, 2022 a
Consent to Criminal Background Check
was filed
involving a dispute between
and
for Change of Name
in the District Court of Todd County.
Preview
77-CV-22-625
Filed In District Court Filed in District Court
Stete of Minnesota State of Minnesota
7/15/2022 1:11 PM
JUL 15 2022
77 ... Cv ...~J - ~5
Criminal History Check Release
Minnesota Statute requires that the Court shall determine whether any person who is seeking to have
their name changed has a criminal history in this or any other state. The court may conduct a search
of national records through the Federal Bureau of Investigation by submitting a set of fingerprints
and the required fee to the Bureau of Criminal Apprehension.
To comply with Minn. Stat. § 259.11, you must supply the following information and attach this
document when you file your application. You must complete a separate form for each party covered
on the application, including a form for each minor that is 10 years of age or older.
If there is a criminal history, both the court administrator and the name change applicant must report
the name change to the Bureau of Criminal Apprehension within ten days of the date of filing. (See
instructions for additional information.)
First Middle Last
Full Name /,,"e;q ffia.ri Q_ Wal-6e.ci<
List Any Other Names By Which You Have Been Known:
it
First Middle Last
L,5a. /Y2ttr1 e_ H(5 u.1S'f
L:sa__ ../111(]._(', e__ !(;· er
Date of Birth 5- 7- ~ 9 (
.kLf'emale □ Male Race u.9 ti;·+e_
I hereby give permission to law enforcement agencies, the Bureau of Criminal Apprehension
and/or the Federal Bureau of Investigation to release criminal history information to the court.
Your Signature
If incomplete, we will not be able to process your application.
Record information will be placed in the name change file that is accessible to the public.
Do Not Write Below This Line
For Bureau of Criminal Apprehension Records
- - - No records found
- - - See attached record(s)
Verifier's Signature
(to be submitted to court)
NAM 103 State ENG Rev 9/07 www.mncourts.gov/forms Page 1 of 1
Document Filed Date
July 15, 2022
Case Filing Date
July 15, 2022
For full print and download access, please subscribe at https://www.trellis.law/.