Fill and Sign the Ecourts Judiciary of New York Form

1 Civil Court of the City of New York County of Index Number In the Matter of the Application of CONSENT TO CHANGE OF NAME OF MINOR I, ______________________________, the natural legal mother father Guardian of ______________________________, a minor, do hereby give my full and free consent to change the name of ______________________________ to ______________________________. I request that the relief requested in the Application for Change of Name on file be granted. DATED this ______ day of ____________, 20______. ____________________________________(signature) 2 CERTIFICATE OF ACKNOWLEDGMENT Use Within the State of New York Use Outside the State of New York State of New York State of New York County of County of On ________________________, before me, the undersigned, personally appeared ______________________________ personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument. On ________________________, before me, the undersigned, personally appeared ______________________________ personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument and that such individual made such appearance before the undersigned in ________________________ (insert city or political subdivision and state or county or other place acknowledgment taken ) (signature and office of individual taking acknowledgment) (signature and office of individual taking acknowledgment) Type or Print Name Type or Print Name