Fill and Sign the Petition Change Name 497321760 Form

Supreme Court of the State of New York County of       In the Matter of the Application of       Index Number                                     PETITION FOR FAMILY CHANGE OF NAME for Leave to Change Their Name(s) To                                           (and       ), by this petition, allege(s) Primary Adult (Second Adult, if any) 1. The present family name is:       2. The new family name which we propose to assume in place and stead of the present family name is       3. The individuals* whose names are included in this application are incorporated herewith are as follows: Present Name Proposed Name Place of Birth Date of Birth Present Age                                                                                                                                                                                     *Primary Adult (and Secondary Adult, if any) and all minors under the age of 18 should be listed. Minors between the ages of 14 and 18 must consent to this change by signing the Consent on page 2. - 1 - 4. No applicant has been convicted of a crime, nor adjudicated a bankrupt, nor are there any judgments or liens against any applicant, nor are there any actions or proceedings pending against any applicant, except as noted.       5. Our present residence is:       6. The reasons for this application are as follows:             7. WHEREFORE, your Petitioner(s) respectfully request(s) that an Order be granted permitting this requested change of name.       Date Signature of Petitioner Signature of Second Adult - 2 - CONSENTS I,       am 14 years of age or over, and less than 18 years of age, and I have read the annexed petition for family change of name, and I consent to the same.             Date Signature I,       am 14 years of age or over, and less than 18 years of age, and I have read the annexed petition for family change of name, and I consent to the same.             Date Signature I,       am 14 years of age or over, and less than 18 years of age, and I have read the annexed petition for family change of name, and I consent to the same.             Date Signature I,       am 14 years of age or over, and less than 18 years of age, and I have read the annexed petition for family change of name, and I consent to the same.             Date Signature VERIFICATION State of New York County of       ss.:       , being duly sworn, deposes and say(s): s/he/they is(are) the petitioner(s) named above, that s/he/the has/have read the petition and know(s) the truth of the contents thereof except for those matters alleged to be on information and belief, and as to those matters, s/he/they believe(s) them to be true, and that the signature(s) of the consenting party (parties) above is/are the true signature(s) of the minor child(ren) who is/are included in the petiton. Signature of Petitioner Signature of Second Adult Sworn to before me this       day of       , 20       Sworn to before me this       day of       , 20             Signature of Notary Public Signature of Notary Public - 3 -