Fill and Sign the I Affirm that I Am Not a Person Who or the Person Whose Name I Seek to Change is Not a Person Who Form

NHJB-2320-F (10/30/2006) Page 1 of 1 THE ST A TE O F NEW H A M PSHIRE JUDI CI AL BR AN C H Cour t N ame: Ca se Nam e: Ca se Num ber: (if k now n) N AM E CH AN GE AFFI RM ATIO N A. I affirm that I am no t a pe rson w ho, or the pe rson whose nam e I see k to ch ang e is not a per son w ho: 1. has been co nv ict ed in an y cour t of a c rim e punishable by im prisonm en t for a term ex ceeding one year ; 2. is a fugitive fro m justi ce; 3. is an unlaw ful use r of or addict ed t o any contr olled subst ance, as de fined i n the Cont rolled Subst ances Ac t, 21 U. S.C. 802; 4. has been ad judicat ed as a m ental de fective or w ho has been co mmitted to a ment al ins titution ; 5. being an alien - a) is illeg ally or unlaw fully in the Unit ed S tates ; or b) ex cept as p rov ided in 18 U. S. C 922 (y)(2), has bee n adm itted to the Unit ed St ates under a nonim migran t visa, as that term is de fined in the Im migration and Nat ionalit y Act , 8 U .S. C. 1101( a)(26) ; 6. has been discha rged from the A rmed For ces und er dishonor able condit ions; 7. hav ing been a cit izen o f the Unit ed St ates , has renounced his cit izenship; 8. is subj ec t to a cou rt or de r that - a) was issued a fter a hear ing o f w hich such per son receiv ed act ual not ice, an d at w hich such per son had an oppo rtuni ty to par ticipat e; b) restr ains such per son from ha rassin g, st alking, or threa tening an in timate partne r of such per son o r child o f su ch in timate par tner or per son, or en gaging in o ther con duct that w ould place an int imate partner in r easonable fear of bo dil y inj ury to the par tner or child; and c) (i) includes a findin g that such per son r epr esen ts a credible t hreat to the physical saf ety of su ch intima te partn er or ch ild; o r (ii) by its terms ex plicit ly pr ohibit s the use , attempted use , or threatened us e o f phy sical force against such int imate pa rtne r or child that w ould r easonably be ex pect ed to c ause bodil y inj ury; or 9. has been co nv ict ed in an y cour t of a misdem eano r crim e o f dom es tic v iolence. B. One o r more of the abov e par agraphs do apply to m e, or to the pe rson w hose nam e I a m see king to chang e, as follow s: (List the pa ragraph # from ab ov e, and w rite any det ails t hat w ould ex plain t o the cour t w hy your pet ition for chan ge of na me should be grant ed not withst and ing . A ttach addit ional sheet s i f neces sar y.) Date Sig nat ure of Petit ioner State of , Coun ty of This instrument w as acknow ledg ed be for e me on by My C ommi ssi on Ex pires Affix Seal , if any Sig nat ure of Not arial O fficer / T itle