Free NC-110 ATTACHMENT TO PETITION FOR CHANGE OF NAME - California

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. PETITION OF (Name of petitioner or petitioners): :

NC-110

Index No.

CASE NUMBER:

FOR CHANGE : NAME OF

NAME AND INFORMATION ABOUT THE PERSON WHOSE NAME IS TO BE CHANGED :

Calendar No.
Attachment of

JUDICIAL Plaintiff(s) Attachment to Petition (form NC-100 or form NC-200)

SUBPOENA

: (You must use a separate attachment-against- person whose name is to be changed. If petitioner is a guardian of a minor, a for each supplemental attachment, Declaration of Guardian (form NC-110G), must also be completed and attached for each minor whose name is to be changed.) : 6. (Continued) Petitioner applies for a decree to change the name of the following person: Self Other b. : (1) Present name (specify): (2) Proposed name (specify): Defendant(s) : (3) .Born .on. (date. of. birth): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ... . ... . .... over 18 years of age and presently under 18 years of age (4) Born at (place of birth): (5) Sex (as stated on original birth certificate): Male Female (6) Current residenceTHE STATE OF NEW YORKzip code): THE PEOPLE OF address (street, city, county, and TO c. Reason for name change (explain):
d. Relationship of the petitioner to the person whose name will be changed: near relative (indicate relationship): (4) (1) self GREETINGS: parent (5) (2) other (specify): guardian (3) WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before e. If the person whose name will be changed is under 18 yearsthe age, provide the names and addresses, if known, of the following the Honorable at of Court persons: located at County of (address): (1) Father (name): in room (name): , on the day of , 20 o'clock in the noon, and at any recessed (address): , at (2) Mother or adjourned date, to testify and give evidence as a witness in this action on the part of the (3) (Only if neither parent is living) Near relatives (names, relationships, and addresses):

,

Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to DECLARATION the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a I declare under penalty of perjury under the laws of the State of California that I am not I am under the result of your failure to comply. jurisdiction of the California Department of Corrections (in state prison or on parole) and I am not I am
required to register as a sex offender under Penal Code section 290. Witness, Honorable Date:

f.

If the person whose name will be changed is 18 years of age or older, that person must sign the following declaration:

, one of the Justices of the
(SIGNATURE OF PERSON WHOSE NAME IS TO BE CHANGED)

Court in

County,

day of

, 20

(TYPE OR PRINT NAME OF PERSON WHOSE NAME IS TO BE CHANGED)

(If petitioner is represented by an attorney, the attorney's signature follows): (Attorney must sign above and type name below) Date:

Attorney(s) for (Each petitioner must sign this petition in the space provided below or, if additional pages are attached, at the end of the last
attachment.) I declare under penalty of perjury under the laws of the State of California that the information in the foregoing petition is true and correct. Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF ATTORNEY)

Office and P.O. Address
(TYPE OR PRINT NAME) (SIGNATURE OF PETITIONER)

Date:

(TYPE OR PRINT NAME) ADD ADDITIONAL SIGNATURE LINES FOR ADDITIONAL PETITIONERS Form Adopted for Mandatory Use Judicial Council of California NC-110 [Rev. January 1, 2003]

Telephone No.: Facsimile No.: (SIGNATURE OF PETITIONER) E-Mail OF PETITIONERS FOLLOWS LAST ATTACHMENT SIGNATUREAddress: Mobile Tel. No.: Code of Civil Procedure, § 1275 et seq. ATTACHMENT TO
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PETITION FOR CHANGE OF NAME