Free Petition for Individual Minor's Change of Name - New York

Civil Court of the City of New York
County of In the Matter of the Application of Index Number PETITION FOR INDIVIDUAL MINORS CHANGE OF NAME

As Parent and Natural Guardian for leave to Change Minor's Name To

I. 2. 3. 4. I am the The Minor's present name is

, by this petition, alleges of a Minor

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 Place of Birth are: Age: Place of Birth:

Date of Birth:

Note: If the Minor was horn in the State of New York you must attach either: a) a Birth Certificate, h) 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 Minor ever been convicted of a crime? 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?.. If your answer is ''YES'' to any of the four questions above, give particulars below in sufficient detail to readily identify the matter referred to: NO

(If additional space is required, attach (a) separate sheet(s) of paper with the details.)

CIV-GP-82M Page 2 (Revised October, 2003)

PETITION FOR INDIVIDUAL MINOR'S CHANGE OF NAME - PAGE 2 6. I have/have not made a previous application to change the Minor's name in this or any other Court. (If you have, give details and reason for this current application below.) (Strike out one)

7.

The reasons for this application are as follows:

8.

WHEREFORE, your Petitioner respectfully requests that an Order be granted permitting this change of name.

Date VERIFICATION

Signature of Petitioner

State of New York, County 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 those matters alleged to be on information and belief, and as to those matters, petitioner believes them to be true.

Signature of Petitioner

Sworn to before me this

day of

20

Signature of Notary Public

CIV-GP-82M Page 2 (Revised October, 2003)

FREE CIVIL COURT FORM No fee may be charged to fill in this form. Form can be found at: http://www.nycourts.gov/courts/nyc/civil/forms.shtml.