On November 30, 2023 a
Request,Application
was filed
involving a dispute between
Johnson, Kumba Theresa,
and
for Change of Name
in the District Court of Hennepin County.
Preview
See lnstructions(NAM101)for help in filling out this form.
State of Minnesota District Court
County ofzfimnggm Court File Number: Z7'W'23" I 8'31}
'
Judicial District: Li "H" Case Type: Name Change
C] Interpreter Requested (Language: )
In the Matter of the Application of:
k vman Tmaesn 3'0""50 u '3 1"
9;? "N
First Middle Last 3'3; 9'5-
9 .54;
First Middle Last U
is:
N
Lu g 3r
Application for Name Change and Other Relief (NAM102)
o
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: ~
StreetAddress: "00 TaflJ/éfiw NW 3b");
City, State 2 1.5 V05
1% WV'L MN 5
5430
3.
County:
Name of
'WDC VI
and date of birth:
applicant"
First Name:
Middle Name: Wife; 4
Last Name: L} 15/1 "[3 m
DateofBirth:
/0/R%7//668
Application for Name Change and Other Relief
"An" n'o cm"... c...- n....-rI-IG ......... .... ISA-.."- 1 4" E
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: Kumqoh
v
Middle Name: W'fim
Last Name: K l Vi a p0€
7 ¥5
Spouse's Date of Birth:
Dé/ aé/
I
Does this application include spouse? D Yes R No
5. Minor children and dates of birth: fiN/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: /A (Not applicable because either the applicant does not have minor
children, ort is application does not include minor children)
First Name:
Middle Name:
Last Name:
Street Address:
City/State/Zip:
If more space is needed, add paper.
OR
Application for Name Change and Other Relief
NAM102 State Eng Rev 7/23 www.mncourts.gov/forms Page 2 of 6
D The non-applicant parent is not known, and the non-applicant parent's name is not
shown on the child's birth certificate.
7. Applicant requests:
W0 have applicant's name changed:
From: I I
Current First Name: Kw M494
Current Middle Name: TA eyejg
Current Last Name: \joé "Jam
To
First Name: Kwaba I
Middle Name: 7AeVeS4 Val: Idem
Last Name:
KIA/A7905
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 furtherrequests 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:
Last Name:
Application for Name Change and Other Relief
NAM102 State Eng Rev 7/23 www.mncourts.gov/forms Page 3 of 6
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:
TOZ
First Name:
Middle Name:
Last Name:
Child 4 -
From:
Current First Name:
Current Middle Name:
Current Last Name:
TOI
First Name:
Middle Name:
Application for Name Change and Other Relief
NAM102 State Eng Rev 7/23 www.mncourts.gov/forms Page 4 of 6
I
Last Name: J
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:
We party to this application has a criminal history.
0R
D The criminal history of the following parties included in this application is:
D The following parties included in this application have been convicted pf a felony:
Date of State
i
Name of Pfison Name of Offense
Offense
9. Does the applicant, spouse, or children have a claim, interest, or lien in or on land in
Minnesota? D Yes o
If Yes, give the name of the person with the claim, interest, or lien, and the legal
description (if youneed more space, include additional pages): -
Application for Name Change and Other Relief
NAM102 State Eng Rev 7/23 www.mncourts.gov/forms Page 5 of 6
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 Affidavit
for Name Change.
12. D Applicant is divorced and seekingto 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:
l declare under penalty of perjury that everything have stated in this document is true and
|
correct. Minn. Stat. §358.116
Date: //' 3D I a0 a: Applicant's ignature:
W
Name: 'C/'e . _
4504
County and state where signed: Address: 0:191 . 03
Hume? in MN City/State/Zip:
Phone:
Email: (ta/Lb /?é¥ "(MU '
'
Date: Co-Applicant'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 lnstructions(NAM101)for help in filling out this form. State of Minnesota District Court County ofzfimnggm Court File Number: Z7'W'23" I 8'31} ' Judicial District: Li "H" Case Type: Name Change C] Interpreter Requested (Language: ) In the Matter of the Application of: k vman Tmaesn 3'0""50 u '3 1" 9;? "N First Middle Last 3'3; 9'5- 9 .54; First Middle Last U is: N Lu g 3r Application for Name Change and Other Relief (NAM102) o 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: ~ StreetAddress: "00 TaflJ/éfiw NW 3b"); City, State 2 1.5 V05 1% WV'L MN 5 5430 3. County: Name of 'WDC VI and date of birth: applicant" First Name: Middle Name: Wife; 4 Last Name: L} 15/1 "[3 m DateofBirth: /0/R%7//668 Application for Name Change and Other Relief "An" n'o cm"... c...- n....-rI-IG ......... .... ISA-.."- 1 4" E 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: Kumqoh v Middle Name: W'fim Last Name: K l Vi a p0€ 7 ¥5 Spouse's Date of Birth: Dé/ aé/ I Does this application include spouse? D Yes R No 5. Minor children and dates of birth: fiN/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: /A (Not applicable because either the applicant does not have minor children, ort is application does not include minor children) First Name: Middle Name: Last Name: Street Address: City/State/Zip: If more space is needed, add paper. OR Application for Name Change and Other Relief NAM102 State Eng Rev 7/23 www.mncourts.gov/forms Page 2 of 6 D The non-applicant parent is not known, and the non-applicant parent's name is not shown on the child's birth certificate. 7. Applicant requests: W0 have applicant's name changed: From: I I Current First Name: Kw M494 Current Middle Name: TA eyejg Current Last Name: \joé "Jam To First Name: Kwaba I Middle Name: 7AeVeS4 Val: Idem Last Name: KIA/A7905 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 furtherrequests 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: Last Name: Application for Name Change and Other Relief NAM102 State Eng Rev 7/23 www.mncourts.gov/forms Page 3 of 6 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: TOZ First Name: Middle Name: Last Name: Child 4 - From: Current First Name: Current Middle Name: Current Last Name: TOI First Name: Middle Name: Application for Name Change and Other Relief NAM102 State Eng Rev 7/23 www.mncourts.gov/forms Page 4 of 6 I Last Name: J 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: We party to this application has a criminal history. 0R D The criminal history of the following parties included in this application is: D The following parties included in this application have been convicted pf a felony: Date of State i Name of Pfison Name of Offense Offense 9. Does the applicant, spouse, or children have a claim, interest, or lien in or on land in Minnesota? D Yes o If Yes, give the name of the person with the claim, interest, or lien, and the legal description (if youneed more space, include additional pages): - Application for Name Change and Other Relief NAM102 State Eng Rev 7/23 www.mncourts.gov/forms Page 5 of 6 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 Affidavit for Name Change. 12. D Applicant is divorced and seekingto 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: l declare under penalty of perjury that everything have stated in this document is true and | correct. Minn. Stat. §358.116 Date: //' 3D I a0 a: Applicant's ignature: W Name: 'C/'e . _ 4504 County and state where signed: Address: 0:191 . 03 Hume? in MN City/State/Zip: Phone: Email: (ta/Lb /?é¥ "(MU ' ' Date: Co-Applicant'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