Fill and Sign the New York Certificate Change Form

Supreme Court of the State of New York County of       In the Matter of the Application of       Index Number                                           CERTIFICATE OF SERVICE for Leave to Change Their Name(s) To                                           I, ______________________________ , certify that I am, __________________ , and at all times during the service of process was, not less than 18 years of age and not a party to the matter concerning which service of process was made. I further certify that the service of this summons and a copy of the complaint was made by: (date)________________________ Mail Service : Regular, first class United States mail, postage fully pre-paid, and addressed to:             Personal Service : By leaving the process with defendant or with an office or agent of defendant at:             Residence Service : By leaving the process with the following adult at:             Certificate of Service - 1 - Under penalty of perjury, I declare that the foregoing is true and correct. Date: ________________________ _____________________________ Signature Print Name       Business Address       City       State       Zip       Certificate of Service - 2 -