Fill and Sign the Change Individual Name Form

Civil Court of the City of New York County of       Index Number In the Matter of the Application of       PETITION FOR INDIVIDUAL ADULT for Leave to Change His/Her Name To CHANGE OF NAME       1.       by this petition, alleges 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:             (If additional space is required, attach (a) separate sheet(s) of paper with the details.) 7. For each of the following questions, place your “initials” in the appropriate column. YES NO CIV-GP-82A page 1 (Revised August, 2009) a) I have any minor children?               b) I have (an) obligation(s) for child support?               Go on to next page CIV-GP-82A page 1 (Revised August, 2009) PETITION FOR INDIVIDUAL ADULT CHANGE OF NAME – PAGE 2 of 3 Index No. If you responded yes to question 7.(b) you must respond to the following: The child support payments are satisfied and up to date               Write the information in the column. 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       Place your initials in the appropriate column YES NO c) I am responsible for spousal support?               If yes, The spousal support payments is/are satisfied and up to date               Write the information in the column. 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. Date Signature of Petitioner CIV-GP-82A page 2 (Revised August, 2009) PETITION FOR INDIVIDUAL ADULT CHANGE OF NAME – PAGE 3 of 3 Index No. 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____ Signature of Notary Public Signature of Petitioner CIV-GP-82A page 3 (revised August 2009) CIV-GP-82A page 2 (Revised August, 2009)