Civil Court of the City of New York
County of ______________________ In the Matter of the Application of Index Number _________________ PETITION FOR INDIVIDUAL MINOR’S CHANGE OF NAME
As Parent and Natural Guardian for leave to Change Minor’s Name To
______________________________________
1. 2. 3. 4. _________ _________ _________ _________ _________ _________ _________ _, by this petition, alleges I am the _____________________________________________________________________ of a Minor The Minor’s present name is _____________________________________________________________. The name which I propose that the M inor will assume in place a nd stead o f the Minor’s present name is: _____________________________________________________________________________________. 5. The Minor’s Age, Date of Birth and Place of Birth are: Age:__________ Date of Birth:________________ Place of Birth: _________________________________________________________________. No te: If the Minor was born in the State of Ne w Yo rk you mu st attach either: a) a Birth C ertificate, 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. 7. The Minor’s present residence is: __________________________________________________________ For each of the following four questions, place your initials in the appropriate column. YES a) Has the M inor ev er been co nvicted of a crim e?.............................................................. ______ b) Has the Minor ever been adjudicated a bankrupt?.......................................................... ______ c) Are there judgments or liens of record against the Minor?............................................. ______ d) Are there any actions or proceedings pending to which the Minor is a party?................ ______ NO ______ ______ ______ ______
If you r answer is “ YES” to any of the fo ur qu estions abo ve, give particulars belo w in su fficient detail to readily identify the matter referred to: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (If add itional space is required , attach (a) sepa rate sheet(s) of pape r with th e deta ils.) CIV-GP-82M Page 1(Revised October, 2003)
PETITION FOR INDIVIDUAL MINOR’S CHANGE OF NAME - PAGE 2 6. I have/have not mad e a previous app lication to chang e the M inor’s name in this o r any other Court. (Strike out one) (If you have, give details and reaso n for th is current ap plication b elow .) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 7. The reasons for this application are as follows: ___________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 8. WH EREFORE, your Petitioner respectfully requests that an Order be granted permitting this change of name.
_______________________________ Date
____________________________________ Signature of Petitioner
VERIFICATION
State o f New Yo rk, Co unty of ____ ___ ___ ___ ss.: ___ ___ ___ ___ ___________________________, being duly sworn, deposes and says: s/he is the petitioner named above, that petitioner has read the petition and knows the truth of the contents thereof except for tho se matters alleged to b e on information and belief, and as to tho se matters, petitioner believes them to be true. __________________________________ Signature of Petitioner
Sworn to before me this _____ day of ____________, 20___ _________________________________________________ Signature of N otary P ublic
CIV-GP-82M Page 2 (Revised October, 2003)