Fill and Sign the Division on Civil Rights File a Complaint State of New Jersey Form

Revised 03/21/2016, CN 10551 - Name Change (Adult), Form APage 1 of 2 Name Street Address City, State, Zip Telephone NumberIn the Matter of the Application of: Your NameTo Assume the Name of: Name you wish to assumeSuperior Court Of New JerseyLaw Division CountyDocket No. (To be filled in by the court)CIVIL ACTION Verified Complaint Including Certification of Plaintiff for Name Change The plaintiff, , whose place of residence is (your name, first, middle, last) , in the City of , County of (street address) (City) , in the State of New Jersey says:1. I am the Plaintiff in this matter.2. I am (check one) am am not a citizen of the United States of America. 3. My social security number is .4. I was born on , in . (month, day, year) (place of birth) 5. I am the (check one) son daughter of and .6. I was raised by and .7. I have since birth been identified by the following names: (first, middle, last) 8. I (check one) have have not been married.9. I (check one) have have no unsatisfied judgments of record, or suits pending against me, except: (enter any recording judgments or pending suits) Revised 03/21/2016, CN 10551 - Name Change (Adult), Form APage 2 of 210.I (check one) have have never been convicted of a crime, and have no criminal charges pending against me, except: (please supply county, municipality, nature, date of crime and/or pending charges) 11. This application (check one) is is not being made with the intent to avoid creditors or criminal prosecution or for other fraudulent purpose.12.I (check one) have have not made any previous applications to assume another name.13.I desire to have the name of: . (first, middle, last) 14.I request this name change in the following reasons: WHEREFORE, plaintiff demands judgment pursuant to N.J.S.A. 2A:52-1 to -4. Signature of Plaintiff Certification I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. Dated Signature of Plaintiff