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IN THE CIRCUIT COURT OF COUNTY ARKANSAS DOMESTIC RELATIONS DIVISION IN RE CHILD S NAME AFFIDAVIT OF CONSENT TO NAME CHANGE STATE OF ARKANSAS COUNTY OF PULASKI SS VERIFICATION COMES NOW the undersigned and states on oath 1. I FATHER S NAME the biological father of CURRENT NAME OF CHILD consent to the name change of this child from CURRENT NAME OF CHILD to NEW NAME OF CHILD. 2. I am over the age of eighteen 18 years and a resident of County Arkansas. FURTHER YOUR AFFIANT SAYETH NOT. NAME ADDRESS PHONE NUMBER SUBSCRIBED AND SWORN TO before me this day of. NOTARY PUBLIC My Commission Expires. I FATHER S NAME the biological father of CURRENT NAME OF CHILD consent to the name change of this child from CURRENT NAME OF CHILD to NEW NAME OF CHILD. 2. I am over the age of eighteen 18 years and a resident of County Arkansas. FURTHER YOUR AFFIANT SAYETH NOT. 2. I am over the age of eighteen 18 years and a resident of County Arkansas. FURTHER YOUR AFFIANT SAYETH NOT. NAME ADDRESS PHONE NUMBER SUBSCRIBED AND SWORN TO before me this day of. NOTARY PUBLIC My Commission Expires. I FATHER S NAME the biological father of CURRENT NAME OF CHILD consent to the name change of this child from CURRENT NAME OF CHILD to NEW NAME OF CHILD. 2. I am over the age of eighteen 18 years and a resident of County Arkansas. FURTHER YOUR AFFIANT SAYETH NOT. NAME ADDRESS PHONE NUMBER SUBSCRIBED AND SWORN TO before me this day of. NOTARY PUBLIC My Commission Expires.

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