Fill and Sign the Civil Court of the City of New York County of Index Number Form

CIV-GP-82M Page 1 (Revised October, 2003)Civil Court of the City of New YorkCounty of Index Number In the Matter of the Application of PETITION FOR INDIVIDUAL MINORS CHANGE OF NAME As Parent and Natural Guardian for leaveto Change Minor’s Name To 1. , by this petition, alleges2.I am the of a Minor3. The Minor’s present name is 4. The name which I propose that the Minor will assume in place and stead of the Minor’s present name is: 5. The Minor’s Age, Date of Birth and lace of Birth are: Age: Date of Birth: Place of Birth: Note: If the Minor was born in 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. 6.The Minors present residence is: 7. For each of the following four questions, place your “initials” in the appropriate column. YES NO a) Has the minor ever been convicted of a crime? ………………………………… b) Has the minor ever been adjudicated a bankrupt? ……………………………… c) Are there judgments or liens of record against the Minor ……………………… d) Are there any actions or proceedings pending to which the Minor is a party? … If your answer is “YES” to any of the four questions above, give particulars below in significant detail to readily identify the matter referred to: (If additional space is required, attach (a) separate sheet(s) of paper with details.) CIV-GP-82M Page 2 (Revised October, 2003) PETITION FOR INDIVIDUAL MINOR’S CHANGE OF NAME – PAGE 2 6. I have / have not made a previous application to change the Minor’s name in this or any other Court. (Select one) (If you have, give details and reason for this current application below.) 7. The reasons for this application are as follows: 8. WHEREFORE, your Petitioner respectfully request that an Order be granted permitting this change of name. Date Signature of Petitioner VERIFICATION State of New York, County of ss.: , being duly sworn, deposes and says:s/he is the petitioner named above, that 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. ______________________________ Signature of Petitioner Sworn to me before this ________ day of _______________ 20_____.______________________________________________ Signature of Notary Public