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Supreme Court of the State of New York County of       In the Matter of the Application of       Index Number                                           PUBLICATION NOTICE for Leave to Change Their Name(s) To                                           Notice is hereby given that an order entered by the Civil Court of ____________ County on __________________ , 20 ______ , Index # ____________ / ______ , copy of which may be examined at the office of the County Clerk, located in ____________ County, ______________________________ (address) , grants the Petitioners the right affected on ____________ , 20 ______ to assume the following names: Present Name: Address:                   New Name: Place of Birth:                   D.O.B.       NOTICE OF PUBLICATION - 1 - Present Name: Address:                   New Name: Place of Birth:                   D.O.B.       Present Name: Address:                   New Name: Place of Birth:                   D.O.B.       Present Name: Address:                   New Name: Place of Birth:                   D.O.B.       NOTICE OF PUBLICATION - 2 - Present Name: Address:                   New Name: Place of Birth:                   D.O.B.       Present Name: Address:                   New Name: Place of Birth:                   D.O.B.       ____________________________________ Petitioner       Print/Type Name ____________________________________ Petitioner       Print/Type Name NOTICE OF PUBLICATION - 3 -