Fill and Sign the Family Name Change 497319554 Form

      Name       Street Address       City, State, Zip       Telephone Number In the Matter of the Application of:       Your Name To Assume the Name of:       Name you wish to assume Superior Court Of New Jersey Law Division       County Docket No.       (To be filled in by the court) CIVIL ACTION Proof of Mailing On       , I, the undersigned, mailed a copy of the Complaint for Change of Name and Order Fixing Date of Hearing in accordance with the rules of Civil Practice and Procedure to: (check all that apply) the Division of Criminal Justice of New Jersey, via certified mail, return receipt requested; the Prosecutor of       County, via regular mail and certified mail, return receipt requested; NOTE: Attached are the green return mail receipt(s) for (check all that apply) the Division of Criminal Justice of New Jersey; the Prosecutor of County. 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 Revised 03/21/2016, CN 10551 - Name Change (Adult), Form D Page 1 of 1