Fill and Sign the Manual for Family Guardians New York State Unified Court Form

Civil Court of the City of New YorkCounty of ______________________Index Number _________________ In the Matter of the Application ofPETITION FORINDIVIDUAL MINOR’SCHANGE OF NAMEAs Parent and Natural Guardian for leaveto Change Minor’s Name To ______________________________________1.________________________________________________________________, by this petition, alleges 2.I am the _____________________________________________________________________ of a Minor3.The Minor’s present name is _____________________________________________________________.4.The name which I propose that the Minor will assume in place and stead of the Minor’s present name is:_____________________________________________________________________________________.5.The Minor’s Age, Date of Birth and Place of Birth are: Age:__________ Date of Birth:________________Place of Birth: _________________________________________________________________.Note: If the Minor was born in the State of New York you must attach either: a) a Birth Certificate, b) aCertified Transcript of such Birth Certificate, or c) a Certificate from the Commissioner or the local Board ofHealth that no such Certificate is available.6.The Minor’s present residence is: __________________________________________________________7.For each of the following four questions, place your initials in the appropriate column.YES NOa) Has the Minor ever been convicted of a crime?.............................................................. ______ ______b) Has the Minor ever been adjudicated a bankrupt?.......................................................... ______ ______c) Are there judgments or liens of record against the Minor?............................................. ______ ______d) Are there any actions or proceedings pending to which the Minor is a party?................ ______ ______If your answer is “YES” to any of the four questions above, give particulars below in sufficient detail toreadily identify the matter referred to:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(If additional space is required, attach (a) separate sheet(s) of paper with the details.)CIV-GP-82M Page 1(Revised October, 2003) PETITION FOR INDIVIDUAL MINOR’S CHANGE OF NAME - PAGE 26.I have/have not made a previous application to change the Minor’s name in this or any other Court. (Strike out one) (If you have, give details and reason for this current application below.)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________7.The reasons for this application are as follows: ___________________________________________________________________________________________________________________________________________________________________________________________________________8.WHEREFORE, your Petitioner respectfully requests that an Order be granted permitting this change ofname.___________________________________________________________________ Date Signature of PetitionerVERIFICATIONState of New York, County of _____________ss.:_______________________________________, being duly sworn, deposes and says:s/he is the petitioner named above, that petitioner has read the petition and knows the truth of the contents thereofexcept for those matters alleged to be on information and belief, and as to those matters, petitioner believes them tobe true.__________________________________Signature of PetitionerSworn to before me this _____ day of ____________, 20____________________________________________________Signature of Notary Public CIV-GP-82M Page 2 (Revised October, 2003)