Document for In the Matter of the Application of Kathryn Emily Hankey for a Change of Name

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                                  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       KOH'WM \n                    Emi lg                        H'OUAV—{x
                                                                                       L4
List AnV Other Names BV Which You Have Been Known:                                                      w'
                                                                                                         fi'

                                  First               Middle                   Last                3'3
                                                                                                       am-




                                                                                                        '3

                                                                                                                 out
Date of Birth      (Hf/05 "HEM Female                 El Male                  Race   Whliea
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
                     WV              WW
                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)



NAM103     State       ENG        Rev 9/07        www.mncourts.qov/forms                    Page   1   of    1