Fill and Sign the Regarding Name Change Form

Supreme Court of the State of New York County of       In the Matter of the Application of       Index Number                                           AFFIDAVIT for Leave to Change Their Name(s) To                                           State of New York ) ) County of       ) ______________________________ , an adult, having been first duly sworn according to law, on oath deposes and states as follows: 1. That ______________________________ is the Petitioner in the above-entitled matter in which Petitioner seeks to change name from ________________________ to ________________________ . 2. That the Petitioner is currently a resident of __________________ County, New York. 3. That the Petitioner is: unmarried and has not been previously married; unmarried and was previously married to ______________________________ , whose current address is ________________________________________________ ; married to ______________________________ , whose address is AFFIDAVIT - 1 - ________________________________________________ and has not been previously married; or married to ______________________________ , whose address is ________________________________________________ and was previously married to ______________________________ , whose address is ________________________________________________ . 4. That the Petitioner does not have any children has ___ children. The names, ages and addresses of Petitioner’s children are as follows: NAME AGE DOB ADDRESS                                                                                                                                                                                          DATED this ______ day of __________________ , 20 ______ . Petitioner       AFFIDAVIT - 2 - Type or Print Name       being duly sworn, deposes and says: I am the petitioner in the above-captioned action. I have read the affidavit and know the contents to be true to my own knowledge, except to those matters alleged on information and belief and a.0s to those matters I believe them to be true. ____________________________________ PETITIONER Sworn to before me on this the       day of       , 20       . ____________________________________ NOTARY AFFIDAVIT - 3 -