New York Petition for Individual Adult Change of Name

PETITION FOR INDIVIDUAL ADULT CHANGE OF NAME

Civil Court of the City of New York

County of Index Number

In the Matter of the Application of

for Leave to Change His/Her Name To

1.

2. My present name is:

3. The name which I propose to assume in place and stead of my present name is:

4. My Age, Date of Birth and Place of Birth are: Age: Date of Birth: Place of Birth:

Note: If you were born in the State Of New York you must attach either: a) a Birth Certificate, b) a Certified Transcript of such Birth Certificate, or c) a Certificate from the Commissioner or the local Board of Health that no such Certificate is available.

5. My present residence is:

6. For each of the following five statements, place your initials in the appropriate column. YES     NO

a) The disclosure and publication of this name change would jeopardize my personal safety      

b) I have been convicted of a crime      

c) I have been adjudicated a bankrupt      

d) There judgments or liens of record against me      

e) There is/are an/action(s) or proceeding(s) pending to which I am a party      

If your answer is "YES" to any of the four questions above, give particulars below in sufficient detail to readily identify the matter referred to:

7. For each of the following questions, place your “initials” in the appropriate column. YES     NO

a) I have any minor children?      

b) I have (an) obligation(s) for child support?      

If you responded yes to question 7.(b) you must respond to the following:

The child support payments are satisfied and up to date      

The amount of child support arrearage that is currently outstanding

The Court that issued the child support order is

The County Child Support Collections Unit that is involved is

c) I am responsible for spousal support?      

If yes,

The spousal support payments is/are satisfied and up to date      

The amount of spousal support arrears that is currently outstanding is

The Court that issued the spousal support order is

8. I have/have not made a previous application to change my name in this or any other Court. (Strike out one)

(If you have, give details and reason for this current application below.)

9. The reasons for this application are as follows:

10. WHEREFORE, your Petitioner respectfully requests that an Order be granted permitting this change of name.

VERIFICATION

State of New York, County of ss.:

being duly sworn, deposes and says:

s/he is the petitioner named above, that petitioner has read the petition and knows the truth of the contents thereof except for those matters alleged to be on information and belief, and as to those matters, petitioner believes them to be true.

Sworn to before me this day of 20