Free PC-910 - Connecticut

AFFIDAVIT RE CHANGE OF NAME PC-910 NEW 6/08

STATE OF CONNECTICUT
RECORDED:

COURT OF PROBATE [To be submitted with form PC-901, Application for Change of Name (Adult)] [Type or print in black ink.] DISTRICT NO.

TO: COURT OF PROBATE, DISTRICT OF IN RE CHANGE OF NAME OF:

The subscriber, being duly sworn, hereby swears, affirms, or avers that: 1. I presently live at: and have been a resident of 2. I Do Do not own real estate located in Connecticut for years.

3. I do not have any outstanding debts that are in arrears. I will notify my creditors of the change of name. 4. A. B. C. I have never been convicted of any offense. I have been convicted of a minor offense. I have been convicted of a criminal offense, as described below.

Due to the nature of my offense, I am obligated to register on the Sex Offender Registry, and, prior to filing this application with the Court, I have notified the Commissioner of Public Safety in accordance with C.G.S. §45a-99.

5. My Social Security number is

6. The purpose of the change of name is not to deceive, defraud, or mislead any person or governmental agency, nor to avoid the legal consequences of a criminal conviction. 7. I Have Have not applied for a change of name previously in either probate court or superior court.

Court name and address:

Affiant ......................................................................................................

Date ...............................................................................

Tel. No. SUBSCRIBED AND SWORN TO BEFORE ME DATE ..................................................................................... Judge, Ass't Clerk, Notary Public, Comm. Sup. Ct. AFFIDAVIT RE CHANGE OF NAME PC-910

RESET