Fill and Sign the Ny Name Change Form

SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF ____________ IN THE MATTER OF THE APPLICATION OF       , Petitioner, FOR LEAVE TO CHANGE       NAME TO: (His/Her)       . (Proposed New Name) PETITION FOR A NAME CHANGE Index # ____________ TO THE SUPREME COURT OF THE STATE OF NEW YORK: The Petition of       respectfully shows this court: 1. The Petitioner resides at No.       , in (Street Address) the       of       , County of       , and has so resided for a period of       years and       months prior to the making of this application. 2. The petitioner       was born at       on the       day of       ,       and is now       years of age. (Attached hereto and made a part hereof is a copy of the petitioner’s birth certificate.) 3. The Petitioner proposes to change said His/Her name to       . 4. The petitioner is a natural born citizen of the United States. 5. The petitioner is / is not married and has / has not been married previously. 6. The petitioner: (Check One):       has never been convicted of a crime.       has been convicted of a crime, the details of which are attached in a separate statement, annexed hereto and made a part hereof. 7. The petitioner has never been adjudicated a bankrupt. 8. There are no judgments or liens of record and no actions pending against your petitioner in any court of this state or of the United States, or any governmental subdivisions thereof, or elsewhere, whether the court be or record or not. 9. There are no claims, demands, liabilities or obligations of any kind whatsoever on a written instrument or otherwise against your infants under the only names by which they are known, which are the names sought herein to be abandoned, and your infants have no creditors who may be adversely affected or prejudiced in any way by the proposed change of name. (If there have been, enter details instead of the previous statement.) 10. The petitioner is / is not responsible for child support obligations. (If there are child support obligations, details are attached in a separate statement.) 11. The petitioner is / is not responsible for spousal support obligations. (If there are spousal support obligations, details are attached in a separate statement.) 12. The grounds of this application to change the petitioner’s name are as follows:                         . 13. No previous application has been made for the relief sought herein. WHEREFORE , petitioner respectfully prays for an order permitting the petitioner       to assume the name       in place of that of       . (Current Name) DATED:       , 20 ______ . (Signature of petitioner) STATE OF NEW YORK ) ss.: INDIVIDUAL VERIFICATION COUNTY OF       ) THIS IS TO CERTIFY that I,       being duly sworn deposes and says: your deponent is the Petitioner in the within action; your deponent has read the foregoing Petition and knows the contents thereof. The same is true to deponent’s own knowledge, except as to the matters therein stated to be alleged on information and belief, and as to those matters deponent believes it to be true. Sworn to before me this       day of       , 20       Petitioner Notary Public