On November 30, 2023 a
Request,Application
was filed
for Change of Name
in the District Court of Hennepin County.
Preview
See Instructions (NAM101) for help in filling out this form.
State of Minnesota District Court
County of: Hennepin Court File Number: 2.?'(N- 23' \Efl qq
Judicial District: 4'" Case Type: Name Change
E Interpreter Requested (Language: Spanish )
In the Matter of the Application of:
Manuel S Marcatoma
First Middle Last
a/k/a
Manuel Salvador Marcatoma Lema
First Middle Last , ;
a/k/a _.
'.
'
Manuel Salvador
'
Marcatoma
First Middle Last I ,
Application for Name Change and Other Relief (NAM102) (.3
Minn. Stat. § 259.10
The undersigned applicant states that:
1. This application is made in good faith, without intent to defraud or mislead.
2. All persons who are asking to have their names changed on this application have lived in
the State of Minnesota for at least six months immediately prior to the date of this
application, and now live at:
Street Address: 3110 Bloomington Avenue
City, State, Zip: Minneapolis, MN 55407
County: Hennepin
3. Name of applicant and date of birth:
First Name: Manuel
Middle Name: Salvador (a/k/a S)
Last Name: Marcatoma (a/k/a Marcatoma Lema)
Application for Name Change and Other Relief
Mini/luv) cum can om. 7/1: mum. man-mm- .mu/hwme Dam. 1 A: c
Date of Birth: 04/07/1963
4. Name of applicant's spouse (if married) and spouse's date of birth: D N/A (not
applicable because applicant is not married)
Spouse's First Name: Maria
Middle Name: H
Last Name: Lema
Spouse's Date of Birth: 08/03/1962
Does this application include spouse? D Yes E No
5. Minor children and dates of birth: E N/A (Not applicable because the applicant does
not have any minor children)
Child's First Name Child's Middle Name Child's Last Name Child's Date
of Birth
1_2_3_4_5
If more than five children, add more paper.
Does this application include any of the minor children listed above? D Yes D No
If Yes, which of the minor children does this application include?
6. The name and address of the non-applicant parent of all minor children included in this
application: E N/A (Not applicable because either the applicant does not have minor
children, or this application does not include minor children)
First Name:
Middle Name:
Last Name:
Street Address:
City/State/Zip:
If more space is needed, add paper.
Application for Name Change and Other Relief
NAM 102 State Eng Rev 7/23 www.mncourts.gov/forms Page 2 of 6
OR
D The nonapplicant parent is not known, and the non-applicant parent's name is not
shown on the child's birth certificate.
7. Applicant requests:
To have applicant's name changed:
From:
Current First Name: Manuel
Current Middle Name: Salvador, a/k/a S
Current Last Name: Marcatoma, a/k/a Marcatoma Lema
To
First Name: Manuel
Middle Name: Salvador
Last Name: Marcatoma
D To have applicant's name changed on the birth record created or maintained by the
Minnesota Department of Health to:
(must reflect your current name or the proposed name if you checked the box above)
First Name:
Middle Name:
Last Name:
D To have the applicant's sex changed on the birth record created or maintained by the
Minnesota Department of Health from to
D To have the Minnesota Department of Health issue and register a replacement birth
record. Applicant further requests the prior birth record be kept confidential and
the replacement birth record not to include any reference to Applicant's:
D former name
D former sex.
D To have the name of applicant's spouse changed:
From
Current First Name:
Current Middle Name:
Current Last Name:
To
First Name:
Middle Name:
Application for Name Change and Other Relief
NAM 102 State Eng Rev 7/23 www.mncourts.gov/forms Page 3 of 6
I
Last Name: I
D To have the names of applicant's minor children changed:
Child 1
From:
Current First Name:
Current Middle Name:
Current Last Name:
To
First Name:
Middle Name:
Last Name:
Child 2
From:
Current First Name:
Current Middle Name:
Current Last Name:
To
First Name:
Middle Name:
Last Name:
Child 3
From:
Current First Name:
Current Middle Name:
Current Last Name:
T OZ
First Name:
Middle Name:
Last Name:
Child 4
From:
Current First Name:
Current Middle Name:
Current Last Name:
T OZ
Application for Name Change and Other Relief
NAM 102 State Eng Rev 7/23 www.mncourts.gov/forms Page 4 of 6
First Name:
Middle Name:
Last Name:
Child 5
From:
Current First Name:
Current Middle Name:
Current Last Name:
To
First Name:
Middle Name:
Last Name:
If more than 5 children, add more paper.
8. Criminal History:
No party to this application has a criminal history.
OR
D The criminal history of the following parties included in this application is:
D The following parties included in this application have been convicted of a felony:
Name of Person Name of Offense Date of State
Offense
9 Does the applicant, spouse, or children have a claim, interest, or lien in or on land in
Minnesota? Yes D No
If Yes, give the name of the person with the claim, interest, or lien, and the legal
description (if you need more space, include additional pages): Manuel Salvador
Marcatoma. Legal Description:
Lot 5 and the South 10 feet of Lot 4, Block 5, Williams Addition to Minneapolis,
Application for Name Change and Other Relief
NAM102 State Eng Rev 7/23 www.mncourts.gov/forms Page 5 of 6
Hennepin County, Minnesota
10. D Applicant is currently involved in a victim or witness protection program.
11. D Applicant is an inmate in a correctional facility and is submitting the Inmate Afiidavit
for Name Change.
12. D Applicant is divorced and seeking to change their name to the legal name on the
applicant's birth certificate and is submitting a certified copy of the Certification of
Dissolution or equivalent court order ending the marriage and a certified copy of the
applicant's birth certificate. No criminal history is required pursuant to Minn. Stat. §
259.11(b) and (c)(3).
13. Other:
ldeclare under penalty of perjury that everything l have stated in this document is true and
correct. Minn. Stat. § 358.116
Date: Ugo-1'5 Applicant's Signature: _
'
Name: Manuel Salvador Marcatoma
County and state where Address: 3110 Bloomington Avenue
A "-N N VP "o 7""signed:
City/State/Zip: Minneapolis, MN 55407
Phone: 612-600-2750
Email:
Date: CoApplicant's Signature (spouse):
Name:
County and state where signed : Address:
City/State/Zip:
Phone:
Email:
Date: Minor's Signature:
(if 14 years old or older)
Name:
Application for Name Change and Other Relief
NAM102 State Eng Rev 7/23 www.mncourts.gov/forms Page 6 of 6
Document Filed Date
November 30, 2023
Case Filing Date
November 30, 2023
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See Instructions (NAM101) for help in filling out this form. State of Minnesota District Court County of: Hennepin Court File Number: 2.?'(N- 23' \Efl qq Judicial District: 4'" Case Type: Name Change E Interpreter Requested (Language: Spanish ) In the Matter of the Application of: Manuel S Marcatoma First Middle Last a/k/a Manuel Salvador Marcatoma Lema First Middle Last , ; a/k/a _. '. ' Manuel Salvador ' Marcatoma First Middle Last I , Application for Name Change and Other Relief (NAM102) (.3 Minn. Stat. § 259.10 The undersigned applicant states that: 1. This application is made in good faith, without intent to defraud or mislead. 2. All persons who are asking to have their names changed on this application have lived in the State of Minnesota for at least six months immediately prior to the date of this application, and now live at: Street Address: 3110 Bloomington Avenue City, State, Zip: Minneapolis, MN 55407 County: Hennepin 3. Name of applicant and date of birth: First Name: Manuel Middle Name: Salvador (a/k/a S) Last Name: Marcatoma (a/k/a Marcatoma Lema) Application for Name Change and Other Relief Mini/luv) cum can om. 7/1: mum. man-mm- .mu/hwme Dam. 1 A: c Date of Birth: 04/07/1963 4. Name of applicant's spouse (if married) and spouse's date of birth: D N/A (not applicable because applicant is not married) Spouse's First Name: Maria Middle Name: H Last Name: Lema Spouse's Date of Birth: 08/03/1962 Does this application include spouse? D Yes E No 5. Minor children and dates of birth: E N/A (Not applicable because the applicant does not have any minor children) Child's First Name Child's Middle Name Child's Last Name Child's Date of Birth 1_2_3_4_5 If more than five children, add more paper. Does this application include any of the minor children listed above? D Yes D No If Yes, which of the minor children does this application include? 6. The name and address of the non-applicant parent of all minor children included in this application: E N/A (Not applicable because either the applicant does not have minor children, or this application does not include minor children) First Name: Middle Name: Last Name: Street Address: City/State/Zip: If more space is needed, add paper. Application for Name Change and Other Relief NAM 102 State Eng Rev 7/23 www.mncourts.gov/forms Page 2 of 6 OR D The nonapplicant parent is not known, and the non-applicant parent's name is not shown on the child's birth certificate. 7. Applicant requests: To have applicant's name changed: From: Current First Name: Manuel Current Middle Name: Salvador, a/k/a S Current Last Name: Marcatoma, a/k/a Marcatoma Lema To First Name: Manuel Middle Name: Salvador Last Name: Marcatoma D To have applicant's name changed on the birth record created or maintained by the Minnesota Department of Health to: (must reflect your current name or the proposed name if you checked the box above) First Name: Middle Name: Last Name: D To have the applicant's sex changed on the birth record created or maintained by the Minnesota Department of Health from to D To have the Minnesota Department of Health issue and register a replacement birth record. Applicant further requests the prior birth record be kept confidential and the replacement birth record not to include any reference to Applicant's: D former name D former sex. D To have the name of applicant's spouse changed: From Current First Name: Current Middle Name: Current Last Name: To First Name: Middle Name: Application for Name Change and Other Relief NAM 102 State Eng Rev 7/23 www.mncourts.gov/forms Page 3 of 6 I Last Name: I D To have the names of applicant's minor children changed: Child 1 From: Current First Name: Current Middle Name: Current Last Name: To First Name: Middle Name: Last Name: Child 2 From: Current First Name: Current Middle Name: Current Last Name: To First Name: Middle Name: Last Name: Child 3 From: Current First Name: Current Middle Name: Current Last Name: T OZ First Name: Middle Name: Last Name: Child 4 From: Current First Name: Current Middle Name: Current Last Name: T OZ Application for Name Change and Other Relief NAM 102 State Eng Rev 7/23 www.mncourts.gov/forms Page 4 of 6 First Name: Middle Name: Last Name: Child 5 From: Current First Name: Current Middle Name: Current Last Name: To First Name: Middle Name: Last Name: If more than 5 children, add more paper. 8. Criminal History: No party to this application has a criminal history. OR D The criminal history of the following parties included in this application is: D The following parties included in this application have been convicted of a felony: Name of Person Name of Offense Date of State Offense 9 Does the applicant, spouse, or children have a claim, interest, or lien in or on land in Minnesota? Yes D No If Yes, give the name of the person with the claim, interest, or lien, and the legal description (if you need more space, include additional pages): Manuel Salvador Marcatoma. Legal Description: Lot 5 and the South 10 feet of Lot 4, Block 5, Williams Addition to Minneapolis, Application for Name Change and Other Relief NAM102 State Eng Rev 7/23 www.mncourts.gov/forms Page 5 of 6 Hennepin County, Minnesota 10. D Applicant is currently involved in a victim or witness protection program. 11. D Applicant is an inmate in a correctional facility and is submitting the Inmate Afiidavit for Name Change. 12. D Applicant is divorced and seeking to change their name to the legal name on the applicant's birth certificate and is submitting a certified copy of the Certification of Dissolution or equivalent court order ending the marriage and a certified copy of the applicant's birth certificate. No criminal history is required pursuant to Minn. Stat. § 259.11(b) and (c)(3). 13. Other: ldeclare under penalty of perjury that everything l have stated in this document is true and correct. Minn. Stat. § 358.116 Date: Ugo-1'5 Applicant's Signature: _ ' Name: Manuel Salvador Marcatoma County and state where Address: 3110 Bloomington Avenue A "-N N VP "o 7""signed: City/State/Zip: Minneapolis, MN 55407 Phone: 612-600-2750 Email: Date: CoApplicant's Signature (spouse): Name: County and state where signed : Address: City/State/Zip: Phone: Email: Date: Minor's Signature: (if 14 years old or older) Name: Application for Name Change and Other Relief NAM102 State Eng Rev 7/23 www.mncourts.gov/forms Page 6 of 6