Fill and Sign the Connecticut Application for Change of Name Adult Form

Petition for Change of Name (Adult) CONNECTICUT PROBATE COURTS PC -901 REV. 10 /17 Petition for Change of Name (Adult) PC -901 RECEIVED : Instructions: 1) An individual 18 years of age or older may use this form to petition for a change of his or her n ame. 2)The petition must be filed in the court for the probate district in which the petitioner resides and accompanied by a) PC-910, Affidavit RE Change of Name, b) a certified copy of the petitioner’s long form b irth certificate and c) two forms o f identification , o ne of which must be p hotographic identification. 3) The c ourt will conduct a search of the sex offender registry and of the registry of offenders convicted of crimes with a deadly weapon and may conduct a full criminal background check. 4) For more information, see Probate Court Rules of Procedure section s 47. 1 and 47.4 . 5) Type or print the form in ink. Use an additional s heet, or PC-180, if more space is needed. Probate Court Name District Number Petitioner’s Current Name: First Middle Last Petitioner’s Address and Telephone Number Date of Birth Place of Birth Name on Birth Certificate (if different ) Name to be Changed to: First Middle Last Spouse ( Name, ad dress and telephone number. ) The Petitioner represents that: A change of name is sought for the following reasons: The purpose of s eeking a change of name is not to deceive, defraud or mislead any person or governmental agency, nor to avoid the legal consequences of a criminal conviction, but solely for the reason(s) stated above. WHEREFO RE, the petitioner requests a change of name to the name stated above. The rep resentations made in this petition are made under the penalty of false statement. Signat ure of Petitioner Type or Print Name Date CONNECTICUT PROBATE COURTS CONFIDENTIAL I NFORMATION/ Petition for Change of Name (Adult) PC-9 01CI REV. 10/17 FOR COURT USE ONLY _______________________________________________________________________________________________ Confidential Information/Petition for Change of Name (Adult) PC-901C I RECEIVED : Probate Court Name District Number In the Matter of ,an adult The s ocial security numbers of the following parties are required in connection with this proceeding for change of name: 1) Pet itioner: Nam e ________________________________________________________________________\ _____________ Soc ial Security Number _______________________________________________________________________