Fill and Sign the Name Change Forms New York State Unified Court System

CIV-GP-82A page 1 (Revised August, 2009)Civil Court of the City of New YorkCounty of Index Number In the Matter of the Application of PETITION FOR INDIVIDUAL ADULT for Leave to Change His/Her Name To CHANGE OF NAME 1. by this petition, alleges2.My present name is: 3. The name which I propose to assume in place and stead of my present name is: 4. My Age, Date of Birth and Place of Birth are: Age: Date of Birth: Place of Birth: Note: If you were born in the State Of New York you must attach either: a) a Birth Certificate, b) a Certified Transcript of such Birth Certificate, or c) a Certificate from the Commissioner or the local Board of Health that no such Certificate is available.5.My present residence is: 6.For each of the following five statements, place your initials in the appropriate column.YESNO a) The disclosure and publication of this name change would jeopardize my personal safety b) I have been convicted of a crime c) I have been adjudicated a bankrupt d) There judgments or liens of record against me e) There is/are an/action(s) or proceeding(s) pending to which I am a party If your answer is ''YES'' to any of the four questions above, give particulars below in sufficient detail to readily identify the matter referred to: (If additional space is required, attach (a) separate sheet(s) of paper with the details.) 7.For each of the following questions, place your “initials” in the appropriate column.YESNOa) I have any minor children? b) I have (an) obligation(s) for child support? Go on to next page PETITION FOR INDIVIDUAL ADULT CHANGE OF NAME – PAGE 2 of 3Index No. CIV-GP-82A page 2 (Revised August, 2009)If you responded yes to question 7.(b) you must respond to the following: The child support payments are satisfied and up to date Write the information in the column. The amount of child support arrearage that is currently outstanding The Court that issued the child support order is The County Child Support Collections Unit that is involved is Place your initials in the appropriate column YESNOc) I am responsible for spousal support? If yes, The spousal support payments is/are satisfied and up to date Write the information in the column. The amount of spousal support arrears that is currently outstanding is The Court that issued the spousal support order is 8. I have/have not made a previous application to change my name in this or any other Court. (Strike out one) (If you have, give details and reason for this current application below.) 9. The reasons for this application are as follows: 10. WHEREFORE, your Petitioner respectfully requests that an Order be granted permitting this change of name. Date Signature of Petitioner PETITION FOR INDIVIDUAL ADULT CHANGE OF NAME – PAGE 3 of 3Index No. CIV-GP-82A page 2 (Revised August, 2009) VERIFICATION State 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 thereof except forthose matters alleged to be on information and belief, and as to those matters, petitioner believes them to be true.Sworn to before me this __________ day of ______________ 20____Signature of Notary Public Signature of PetitionerCIV-GP-82A page 3 (revised August 2009)