Fill and Sign the Petition for Individual Change of Name for Minor New York Form

Civil Court of the City of New York County of       Index Number In the Matter of the Application of PETITION FOR INDIVIDUAL MINORS       CHANGE OF NAME As Parent and Natural Guardian for leave to Change Minor’s Name To       1.       , by this petition, alleges 2. I am the       of a Minor 3. The Minor’s present name is       4. The name which I propose that the Minor will assume in place and stead of the Minor’s present name is:       5. The Minor’s Age, Date of Birth and lace of Birth are: Age:       Date of Birth:       Place of Birth:       Note: If the Minor was 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. 6. The Minors present residence is:       7. For each of the following five statements, place your initials in the appropriate column. YES NO a) The Minor’s personal safety would be jeopardized by the disclosure of this name change. b) The Minor has been convicted of a crime c) The Minor has been adjudicated a bankrupt d) There are judgments or liens of record against the Minor e) There is/are actions or proceedings pending to which the Minor is a party If you responded “YES” to any of the five statements above, please explain:                   (If additional space is required, attach (a) separate sheet(s) of paper with details.) CIV-GP-82M Page 1 (Revised August 2009) 8. I have / have not made a previous application to change the Minor’s name in this or any other Court. (Select 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 request that an Order be granted permitting this change of name.             Date Signature of Petitioner VERIFICATION State of New York, County of       ss.:       , being duly sworn, deposes and says: s/he is the petitioner named above, that petition and knows the truth of the contents thereof except for those matters alleged to be on information and belief, and as to those matters, Petitioner believes them to be true. Sworn to me before this ______day of _______________ 20_____ . Signature of Notary Public Signature of Petitioner CIV-GP-82M Page 2 (Revised August 2009)