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11155e PDF
11155e PDF
Application to change an
adults name
To use this application:
you must be 16 years of age or older, and
you must have lived in Ontario for at least the past 12 months.
Personal information on this form is collected under the authority of the Change of Name Act, R.S.O. 1990, c.C.7. It will be
used to determine whether a change of name can be granted, to register and record the change of name, to publish the
change of name in the Ontario Gazette, to provide certified copies of the registration, certificates and search notices and for
statistical, research, medical, law enforcement, corrections, adoption and adoption disclosure purposes.
Questions about this collection should be directed to the:
Office of the Registrar General
PO Box 4600, Thunder Bay ON P7B 6L8
Telephone 1 800 461-2156 or 416 325-8305.
1 800 461-2156
or
416 325-8305
Contents
PART 1
Personal information
PART 2
Additional information
P A R T
Clear Form
P E R S O N A L
I N F O R M A T I O N
Sex
Mailing address
Street number and street name
Apt/Unit/Suite
Buzzer No.
PO Box or RR
City/Town/Village
document described in
Part 5.
Province
Postal code
How long have you lived in Ontario? Print the number of years or the number of months.
Years
Months
or
Yes
HELP NOTE 2
Day
Year
Province or State
Country
What do you want your new name to be? (See HELP NOTE 2 on the left.)
Middle names
First name
For office use only. Please do not write anything in this box.
Change of name registration number:
Approved by:
Page 1
Yes... What was your spouse/partners name before you got married?
First name
Middle names
Day
Year
NOTE 3
wo people of the
opposite sex or
Province or State
Country
Have you ever signed a document called a Joint Declaration of Conjugal Relationship
(Form 3, Change of Name Act) and sent it to the Office of the Registrar General?
(Put an X in one box. See HELP NOTE 3.)
No
Yes... What is the name of the other person who signed the
Joint Declaration of Conjugal Relationship (Form 3, Change of Name Act) with you?
First name
Middle names
Act).
Last name or family name
Day
Year
NOTE 4
ou can only
revoke a Joint
Declaration of
Conjugal Relationship
Have you officially cancelled the declaration by submitting Form 4 of the Change of Name Act?
(Put an X in one box. See HELP NOTE 4.)
No
Yes
by completing and
sending to the Office
of the Registrar
General a Declaration
that Conjugal
Relationship has
Ended (Form 4,
Change of Name Act).
Page 2
What was your mothers last name or family name when she was born?
Your mothers last name or family name now
Page 3
Month
Day
Year
Middle names
Middle names
Country
If you changed your name more than once, use a separate piece of paper.
For every name change, print:
the month, day and year you changed your name
your full name before you changed it
your full name after you changed it.
the province or state and country where you changed it.
Have you ever applied for a name change before and been refused?
(Put an X in one box.)
No
Page 4
Yes
1. Are you aware of any outstanding court proceedings against you, other than outstanding
criminal charges? This includes a proceeding that has been started but has not yet gone to
court or has not yet been decided.
Court file number
No
Court name
2. Are you aware of any outstanding law enforcement orders against you, including any warrant,
prohibition order, drivers licence suspension, probation order or parole order?
No
4. Have you ever been found guilty and discharged of a criminal offence? If the Criminal Records
Act (Canada) requires that the record of the offence or offences be purged, put an X in the No
box.
No
5. Have you ever been found guilty of a criminal offence for which an adult sentence has been
imposed under the under the Youth Criminal Justice Act (Canada)? If the record of the offence
or offences is required to be destroyed under the Youth Criminal Justice Act (Canada), put an X
in the No box.
No
6. Are you aware of any pending criminal charges against you? This includes a proceeding that has
been started but has not yet gone to court or has not yet been decided.
Court file number
No
Court name
Address of the court
Page 5
E. Financial information
HELP NOTE 5
his includes
judgements and fines.
Has any court or tribunal ordered you to pay money that you have not yet paid?
(Put an X in one box. See HELP NOTE 5.)
Court file number
No
Name of court
HELP NOTE 6
ersonal property
includes your
Are you aware if a sheriff has been directed to take your real and personal property to enforce an
outstanding judgement?
(Put an X in one box. See HELP NOTE 6.) This question asks about any unsatisfied execution.
Writ number
possessions (e.g.,
furniture, vehicle). Real
property includes real
estate.
No
Name of sheriff
Address of sheriff
HELP NOTE 7
Are you aware of any liens or security interests against your personal property?
Yes... Name the person who has the lien or security interest
Registration number
promise to do.
(e.g. for a new furnace.)
Are you aware of any financing statements registered under the Personal Property Security Act
that name you as a debtor?
HELP NOTE 8
here could be a
financing statement
No
Registration number
Details of bankruptcy
ou are an undischarged
bankrupt if you have
Page 6
Go to last page
P A R T
G I V I N G N O T I C E T H A T Y O U
C H A N G I N G Y O U R N A M E
HELP NOTE 10
wo people of the
opposite sex or
If you are not married and did not sign a Joint Declaration of Conjugal Relationship (Form 3,
Change of Name Act), do not fill in Part 2. Go to Part 3.
Joint Declaration of
If you signed a Joint Declaration of Conjugal Relationship (Form 3, Change of Name Act) but
officially cancelled it by completing and sending to the Office of the Registrar General, Form 4 of
the Change of Name Act, do not fill in Part 2. Go to Part 3.
Conjugal Relationship
(Form 3, Change of
1. Carefully remove this page from the application and fill in the section below.
usually do this so
they can legally
change their last
names (Form 1,
PLEASE TEAR OFF HERE
A R E
Middle names
What do you want your new name to be? Make sure you print the new name exactly the way you
want it.
First name
Middle names
Apartment/Unit/Suite
City/Town/Village
Province
Postal code
X
APPLICATION TO CHANGE AN ADULTS NAME PART 2
Page 7
P A R T
( C O N T I N U E D)
Middle names
Mailing address
PO Box or RR
H E L P N O T E 11
wo people of the
Apartment/Unit/Suite
City/Town/Village
Postal code
Province
opposite sex or
How are you related to the person applying for a change of name?
(Put an X in one box.)
married /
spouse
sign a Joint
Declaration of Conjugal
Relationship (Form 3,
Change of Name Act).
They usually do this
so they can legally
change their last
names (Form 1,
Change of Name Act).
By signing below, I agree that I have been informed of the proposed change of name on page 7.
Sign your name here
X
Personal information on this form is collected under the authority of the Change of Name Act, R.S.O. 1990, c.C.7. It
will be used to determine whether a change of name can be granted, to register and record the change of name, to
publish the change of name in the Ontario Gazette, to provide certified copies of the registration, certificates and
search notices and for statistical, research, medical, law enforcement, corrections, adoption and adoption disclosure
purposes.
Questions about this collection should be directed to the:
Office of the Registrar General
PO Box 4600, Thunder Bay ON P7B 6L8
Telephone 1 800 461-2156 or 416 325-8305.
Page 8
P A R T
G E T T I N G
C O N S E N T
TO
C H A N G E
Y O U R
N A M E
4. If your parents or guardians refuse to give permission, you may ask the Ontario Court of Justice
to let you apply without consent. If you get a court order that lets you apply without consent, put
the court order with your application.
First name
What do you want your new name to be? Make sure you print the new name exactly the way
you want it.
Middle names
First name
Day
Year
Page 9
P A R T
( C O N T I N U E D)
First name
Mailing address
PO Box or RR
City/Town/Village
Postal code
Province
Middle names
You alone have legal custody of the child. (You must send the custody papers with this form.)
You do not have custody, but a court order or separation agreement says this persons name
may not be changed without your agreement. (You must send the court order or separation
agreement with this form.)
By signing below, I agree to the change of name for the child named on page 9.
Sign your name here
X
Personal information on this form is collected under the authority of the Change of Name Act, R.S.O. 1990, c.C.7. It
will be used to determine whether a change of name can be granted, to register and record the change of name, to
publish the change of name in the Ontario Gazette, to provide certified copies of the registration, certificates and
search notices and for statistical, research, medical, law enforcement, corrections, adoption and adoption disclosure
purposes.
Questions about this collection should be directed to the:
Office of the Registrar General
PO Box 4600, Thunder Bay ON P7B 6L8
Telephone 1 800 461-2156 or 416 325-8305.
Page 10
P A R T
P R O V I N G
L I V E D
I N
H O W
L O N G
O N T A R I O
Y O U
H A V E
You must use Part 4 to prove you have lived in Ontario for at least the past 12 months.
You must find someone who will say how long you have lived in Ontario. We call this
person a guarantor.
Any of the following people who know that you have lived in Ontario for at least the past 12
months can be a guarantor:
1. Provincial judges appointed under the Courts of Justice Act.
2. Justices of the peace appointed under the Justices of the Peace Act.
3. Chiefs of Indian bands that are located in Ontario.
4. Persons authorized under the Marriage Act to solemnize marriages.
5. Legally qualified medical practitioners.
6. Members of The Law Society of Upper Canada.
7. Heads of municipal councils in Ontario.
8. Clerks of municipalities in Ontario.
9. Principals of elementary and secondary schools, as defined in the Education Act.
10. Managers or signing officers of Ontario branches of banks listed in Schedule I or II of the
Bank Act (Canada), loans corporations, trust corporations, credit unions and caisses populaires.
The list above is not an endorsement by the Office of the Registrar General of professional status or
recognition of superior qualifications.
If you cant identify anyone from this list to act as a guarantor, you must find someone other than a
relative who has known you for at least five years, and knows that you have lived in Ontario for at
least the past 12 months.
Heres what to do
1. Carefully remove Part 4 from the application.
2. Print your name in the space provided below.
3. Find someone to be a guarantor and ask them to fill in the Guarantors statement on page 12.
4. After your guarantor has filled in and signed the Guarantors statement, put it with the rest of
your application.
Middle names
Page 11
P A R T
( C O N T I N U E D )
First name
Mailing address
PO Box or RR
City/Town/Village
Postal code
Province
How long have you known the person named on page 11?
Years
Months
Year
X
Personal information on this form is collected under the authority of the Change of Name Act, R.S.O. 1990, c.C.7. It
will be used to determine whether a change of name can be granted, to register and record the change of name, to
publish the change of name in the Ontario Gazette, to provide certified copies of the registration, certificates and
search notices and for statistical, research, medical, law enforcement, corrections, adoption and adoption disclosure
purposes.
Questions about this collection should be directed to the:
Office of the Registrar General
PO Box 4600, Thunder Bay ON P7B 6L8
Telephone 1 800 461-2156 or 416 325-8305.
Page 12
P A R T
D O C U M E N T S
Y O U
M U S T
S E N D
W I T H
T H I S
A P P L I C A T I O N
If you were born outside of Canada, you must send the following
documents:
If you are a Canadian Citizen send:
photocopy of Canadian Citizenship Card (both sides)
photocopy of original birth certificate or photocopy of certified copy of birth registration from
country of birth
photocopies of all change of name certificates if you have changed your name before
all court certified copies of court orders (if applicable)
Page 13
or
If you are born in Canada, submit all original birth certificate(s). If you do not have a birth
certificate, you must obtain one and submit it with your change of name application.
If you are born outside of Canada, submit a photocopy of the original birth certificate, or a
photocopy of the certified copy of birth registration from the country in which you were born.
For applicants born outside of Canada, you are required to submit one of the following
(mandatory for those born outside of Canada)
or
or
Additional Evidence:
Photocopies of all previous change of name certificates, if applicable.
Page 14
P A R T
S I G N I N G
Y O U R
A P P L I C A T I O N
Before you send us your application, you must first sign the next page. You must sign this
statement in front of a person called a commissioner for taking affidavits or a commissioner for
taking oaths. The statement says you have followed all the steps and all the information is true.
It is a serious crime under the Criminal Code of Canada to make a false statement.
There are commissioners in every community who will provide this service for you for little
or no cost. Here are some examples of commissioners:
Heres what to do
1. Make sure all the documents you need are filled in and signed by the necessary people.
2. Make sure you have all the birth certificates and other documents as explained in Part 5.
3. Bring the application and all of the documents to the commissioner. Sign at the X on the
next page in front of the commissioner.
4. The commissioner will fill in and sign the Statutory declaration form on the next page.
5. Make sure the commissioner puts his or her initials beside any changes
or corrections you have made on the application.
Page 15
P A R T
HELP NOTE 12
6, 7 or 8, the applicant
and commissioner must
initial the changes.
( C O N T I N U E D )
declaration conscientiously believing it to be true and knowing that it is of the same force
and effect as if made under oath.
of .........................................................................................................................................................
(county, district or regional municipality where declaration made)
(month)
(year)
..............................................................................
Commissioner for taking Affidavits Signature
Commissioners seal/stamp
Page 16
P A R T
A D D I T I O N A L
I N F O R M A T I O N
Number of applications
F E E S
For every
adult name
change ............... $137.00
For each child
17 years of age
or younger, if
they change
their name at the
same time as
one of their
parents ................. $22.00
$
How are you paying?
(Put an X in one box.)
cheque
money order
VISA
MasterCard
American Express
Card number
X
What language should we use if we need to contact you?
(Put an X in one box.)
English
French
Work telephone
Page 17